WEBSITE OF THE STATE OF SOUTH DAKOTA DEPARTMENT OF HEALTH
Kim Malsam-Rysdon, Secretary of Health

South Dakota Dental Care Full-Time Equivalent (FTE) Survey

Identifiable information from this survey will be used for calculating population-to-provider ratios for the State's applications for geographic and population health professional shortage area (HPSA) and medically underserved area/population (MUA/MUP) designations for primary care. This information must be collected for each relevant dentist practicing in the State; complete and accurate responses will greatly assist the State in identifying areas with limited access to dental care so that these areas can be made eligible to receive additional health care resources. Please respond to all questions. Information provided is confidential and will not be provided with other entities. Contact DeAnn Sprenger at 605-773-2679 for assistance.

Dentist

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* Dentist Status

Is Dentist a Resident or Intern?
Is Dentist a Current J-1 Visa Waiver Program Participant?
Is Dentist a Federal Employee?
Is Dentist a National Health Service Corps (NHSC) Employee?
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Practice Address 1 (Main)
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* Hours per week in DIRECT patient care activities (office and hospital inpatient) at this site
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* Auxiliaries include Dental Hygienist, Dental Assistants, Dental Therapists and Dental Technicians

Percentage of the following patient groups the Dentist sees at practice. If unknown please estimate:

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Practice Address 2 (Additional)
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* Hours per week in DIRECT patient care activities (office and hospital inpatient) at this site
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* Auxiliaries include Dental Hygienist, Dental Assistants, Dental Therapists and Dental Technicians

Percentage of the following patient groups the Dentist sees at practice. If unknown please estimate:

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Practice Address 3 (Additional)
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* Hours per week in DIRECT patient care activities (office and hospital inpatient) at this site
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* Auxiliaries include Dental Hygienist, Dental Assistants, Dental Therapists and Dental Technicians

Percentage of the following patient groups the Dentist sees at practice. If unknown please estimate:

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Practice Address 4 (Additional)
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* Hours per week in DIRECT patient care activities (office and hospital inpatient) at this site
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* Auxiliaries include Dental Hygienist, Dental Assistants, Dental Therapists and Dental Technicians

Percentage of the following patient groups the Dentist sees at practice. If unknown please estimate:

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Practice Address 5 (Additional)
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* Hours per week in DIRECT patient care activities (office and hospital inpatient) at this site
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* Auxiliaries include Dental Hygienist, Dental Assistants, Dental Therapists and Dental Technicians

Percentage of the following patient groups the Dentist sees at practice. If unknown please estimate:

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Practice Address 6 (Additional)
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*
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*
* Hours per week in DIRECT patient care activities (office and hospital inpatient) at this site
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*
* Auxiliaries include Dental Hygienist, Dental Assistants, Dental Therapists and Dental Technicians

Percentage of the following patient groups the Dentist sees at practice. If unknown please estimate:

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** Note: Sliding Fee is a formal posted up-front discount policy based on income or ability to pay and is tied to the Federal Poverty Levels. (see http://aspe.hhs.gov/POVERTY/) - bad debt write-offs are not included.

Thank you for your assistance with this important effort.