Welcome to the Teeth-on-the-Go Survey

 
Please complete the following questions.  Required questions are marked with a red asterisk: *  
 
Summary of the Presentation

1
When did you use the Teeth-on-the-Go kit?
Month:       Year:

 

2
How did you use the kit?
One-on-One
Small Group Meeting
Classroom
Assembly
Community Meeting
Dental Office
Other

 

3
To whom did you present the kit? (i.e., students, Head Start group, community group, etc.)

 

4
How many children did you present to? *


 

5
Please tell us how many children, in each age group, participated in the program? *
Under 5 years old:
Between 5 and 7:
Between 8 and 10:
Between 11 and 13:
Other age groups:

 

6
How many adults participated? *
 

 

7
Where did you make your presentation? *
Name of school, facility:
 
City:
 
State:
 
Zip:

 

8
Who gave the presention? *
Name:  
Profession:
 

 

9
Please provide contact information for the presenter: *
Name
(if different from above)
Address 1:  
Address 2: (optional)
City:  
State:  
Zip:
Phone:
Email:
 

 

Rate the Kit's Effectiveness

10
On a scale from 1 to 10 (where 10 is excellent), please rate the kit's effectiveness in educating your audience and improving their oral health knowledge *  

 

11
How often do you plan to use the kit? *
 

 

12
What did you best like about the kit?

 

13
What would you improve about the kit?

 

14
Anything else to share with us?



As a thank you for completing the survey, we will send you 50 toothbrushes for you to distribute as you wish!