1. Please check the category which best describes your practice:
      
      
      
      
      2. Do you currently employ a dental hygienist(s) in your practice?
      
        (If Yes              
      3) If a dental hygiene education program were to be developed at the Institute of Medical Education (IME) in San Jose, CA how many of your present employees, patients or other acquaintances would be interested in enrolling?
      Employees              Patients              Others       

      4) If a dental hygiene education program were to be developed in San Jose, CA, would you support or help the hygiene program?
      a.       
      b.                     )
      5) Have you ever taught in a dental hygiene, dental assisting, dental school program?
      a.       
      b.                     )
      6. Would you be willing to participate in any of the following supportive endeavors associated with the development of a dental hygiene program at IME?
                         
        
                   
                         
      7) Do you think the community can provide the patient pool to enable dental hygiene students to learn proper techniques required by the program?
      a)       
      b)       
      8) Would you be willing to help recruit patients, students, faculty for the dental hygiene education program?
      a)       
      b)              (Please identify the population you would help recruit              )

CONTACTS
Full name:  Contact #*
Street Address* Email*
Thank you for your time.
Please complete sooner, and send your survey to:
Tran Trinh, RDH, MS
Institute of Medical Education
130 Park Center Plaza
San Jose, CA 95113.