Your Advanced Dental Compliance Survey

Your Full Name

Email Address

Dental Practice Name

Phone with Area Code

The overall goals of the on-site consultation were clearly defined to Doctors*: The overall goals of the on-site consultation were clearly defined to Doctors*: STRONGLY DISAGREE DISAGREE NEUTRAL AGREE STRONGLY AGREE N/A

The overall goals of the on-site consultation were clearly defined to the Dental Team*: The overall goals of the on-site consultation were clearly defined to the Dental Team*: STRONGLY DISAGREE DISAGREE NEUTRAL AGREE STRONGLY AGREE N/A

We found the time dedicated to this assessment be be helpful and appropriate for the Doctors*: We found the time dedicated to this assessment be be helpful and appropriate for the Doctors*: VERY INAPPROPRIATE INAPPROPRIATE NEUTRAL APPROPRIATE VERY APPROPRIATE N/A

We found the time dedicated to this assessment be be helpful and appropriate for the Dental Team*: We found the time dedicated to this assessment be be helpful and appropriate for the Dental Team*: VERY INAPPROPRIATE INAPPROPRIATE NEUTRAL APPROPRIATE VERY APPROPRIATE N/A

Overall, We found the documentation provided by Dr. Rossoff to be helpful in our understanding of the issues of risk:* Overall, We found the documentation provided by Dr. Rossoff to be helpful in our understanding of the issues of risk:* STRONGLY DISAGREE DISAGREE NEUTRAL AGREE STRONGLY AGREE N/A

Overall, We found the recommendations made to be*: Overall, We found the recommendations made to be*: VERY INAPPROPRIATE INAPPROPRIATE NEUTRAL APPROPRIATE VERY APPROPRIATE N/A

Please rate the Value (High, Some, Low) of this ADC document to you and your Team - The ADC Report*: Please rate the Value (High, Some, Low) of this ADC document to you and your Team - The ADC Report*: HIGH SOME LOW N/A

Please rate the Value (High, Some, Low) of this ADC document to you and your Team - The Documentation Rating Worksheet*: Please rate the Value (High, Some, Low) of this ADC document to you and your Team - The Documentation Rating Worksheet*: HIGH SOME LOW N/A

Please rate the Value (High, Some, Low) of this ADC document to you and your Team - The Infection Control Rating Worksheet*: Please rate the Value (High, Some, Low) of this ADC document to you and your Team - The Infection Control Rating Worksheet*: HIGH SOME LOW N/A

Please rate the Value (High, Some, Low) of this ADC document to you and your Team - The HIPPAA/Confidentiality Rating Worksheet*: Please rate the Value (High, Some, Low) of this ADC document to you and your Team - The HIPPAA/Confidentiality Rating Worksheet*: HIGH SOME LOW N/A

Please rate the Value (High, Some, Low) of this ADC document to you and your Team - The Communication/Conflict Resolution Worksheet*: Please rate the Value (High, Some, Low) of this ADC document to you and your Team - The Communication/Conflict Resolution Worksheet*: HIGH SOME LOW N/A

Please rate the Value (High, Some, Low) of this ADC document to you and your Team - The Adverse Event Rating Worksheet*: Please rate the Value (High, Some, Low) of this ADC document to you and your Team - The Adverse Event Rating Worksheet*: HIGH SOME LOW N/A

Please rate the Value (High, Some, Low) of this ADC document to you and your Team - The ADC Reference Manual*: Please rate the Value (High, Some, Low) of this ADC document to you and your Team - The ADC Reference Manual*: HIGH SOME LOW N/A

Please rate the Value (High, Some, Low) of this ADC document to you and your Team - The Workplan Summary Report*: Please rate the Value (High, Some, Low) of this ADC document to you and your Team - The Workplan Summary Report*: HIGH SOME LOW N/A

We are able to interpret the ADC Rating System as intended?* We are able to interpret the ADC Rating System as intended?* Yes No

Please indicate your level of confidence that the Workplan Recommendations are achievable in your practice for the critical risk areas assessed - Documentation*: Please indicate your level of confidence that the Workplan Recommendations are achievable in your practice for the critical risk areas assessed - Documentation*: ACHIEVABLE NOT SURE NOT ACHIEVABLE

Please indicate your level of confidence that the Workplan Recommendations are achievable in your practice for the critical risk areas assessed - Infection Control*: Please indicate your level of confidence that the Workplan Recommendations are achievable in your practice for the critical risk areas assessed - Infection Control*: ACHIEVABLE NOT SURE NOT ACHIEVABLE

Please indicate your level of confidence that the Workplan Recommendations are achievable in your practice for the critical risk areas assessed - HIPPAA/Confidentiality*: Please indicate your level of confidence that the Workplan Recommendations are achievable in your practice for the critical risk areas assessed - HIPPAA/Confidentiality*: ACHIEVABLE NOT SURE NOT ACHIEVABLE

Please indicate your level of confidence that the Workplan Recommendations are achievable in your practice for the critical risk areas assessed - Communication/Conflict Resolution*: Please indicate your level of confidence that the Workplan Recommendations are achievable in your practice for the critical risk areas assessed - Communication/Conflict Resolution*: ACHIEVABLE NOT SURE NOT ACHIEVABLE

Please indicate your level of confidence that the Workplan Recommendations are achievable in your practice for the critical risk areas assessed - Adverse Event/Decision Making*: Please indicate your level of confidence that the Workplan Recommendations are achievable in your practice for the critical risk areas assessed - Adverse Event/Decision Making*: ACHIEVABLE NOT SURE NOT ACHIEVABLE

How would you rate the feelings of your Dental Team towards this consultative process?* [On a scale from 1 to 5; 1 being low and 5 being high, Indicate your satisfaction.] How would you rate the feelings of your Dental Team towards this consultative process?* [On a scale from 1 to 5; 1 being low and 5 being high, Indicate your satisfaction.] 1 2 3 4 5

Please indicate the degree to which this Risk Management assessment met your expectations* [On a scale from 1 to 5; 1 being low and 5 being high, Indicate your satisfaction.] Please indicate the degree to which this Risk Management assessment met your expectations* [On a scale from 1 to 5; 1 being low and 5 being high, Indicate your satisfaction.] 1 2 3 4 5

How likely is it that you would recommend Advanced Dental Compliance to a colleague?* [On a scale from 1 to 5; 1 being not likely to 5 being highly likely.] How likely is it that you would recommend Advanced Dental Compliance to a colleague?* [On a scale from 1 to 5; 1 being not likely to 5 being highly likely.] 1 2 3 4 5

Please include any additional Message or Remarks: