New project assessment form
Before completing this form please read the information provided on the Dentaid website www.dentaid.org . Please see the page about our work overseas https://dentaid.org/overseas/ and the page which shows other projects we have helped https://dentaid.org/what-our-partners-say/ This will help you understand if your project fits our criteria before you apply.
This form is designed to help Dentaid get a better understanding of your organisation, the work you are doing and the community you serve. This will help us assess if we can assist you and how we might best do that. If you cannot answer all the questions precisely please give your best estimate or tell us if you cannot answer. Please give us as much information as you can. It would also be helpful if you can email photos to support the information you provide. Please email jac@dentaid.org with photos or any questions about the form.
We receive a high number of requests for help and unfortunately we do not have the resources to help everyone. We will try to acknowledge receipt of your application within two weeks but it may take much longer to receive a decision from us. Please bear with us as we try to make careful decisions about how we best use our limited resources.
About you
Full name *
Your answer
Email Address *
Your answer
Telephone Number *
Your answer
Contact Address *
Your answer
Profession and current position *
Your answer
Relationship to the organisation *
Your answer
About the organisation
Name of organisation *
Your answer
Location (Area) *
Your answer
Location (Country) *
Your answer
Full postal adress of organisation *
Your answer
Email contact for organisation *
Your answer
International telephone number *
Your answer
Organisation website address, if you have one
Your answer
Who owns or runs the organisation *
Your answer
Charity or government registration number *
Your answer
Year the organisation was founded *
MM
/
DD
/
YYYY
Type of organisation *
Organisation’s mission or purpose *
Your answer
Number of people working for your organisation (Paid) *
Your answer
Number of people working for your organisation (Voluntary) *
Your answer
Your Dental Personnel
Do you have a trained and qualified dental professional to work for you *
Dental Professional Details
Full Name *
Your answer
Qualification *
Your answer
Year Qualified *
MM
/
DD
/
YYYY
Where did they train? *
Your answer
How many hours per week/month does this person work for your organisation *
Your answer
Do you have any other dental personnel working for the organisation? (Dental nurses, hygienists or other) Please list their names and roles *
Your answer
Do you know a dental engineer who can install, maintain and repair dental equipment? *
Your Dental Programme
What premises do you have available to use for your dental provision? (Photos are helpful) *
Your answer
What size (in m²) is the space available to you? *
Your answer
Do you have an electricity supply? *
Do you have a water supply? *
What dental equipment do you have currently in working order? *
Your answer
What dental treatments do you currently provide, if any? *
Your answer
What charges do you make for dental treatments? *
Your answer
Do you consider these charges to be a charitable rate? *
Your answer
Do you make any provision for people who cannot afford the charges? *
Your answer
Do you have any support or funding for your services from the government or other NGO’s? *
Your answer
What is the distance to the nearest dental service from your location? *
Your answer
What is the distance to the nearest referral clinic or hospital for more complicated treatments that you are not able to provide? *
Your answer
Where do you get your supply of dental materials and consumables from? *
Your answer
How many patients do you currently treat each month? *
Your answer
Do you provide any mobile outreach dental services? If yes, how often? *
Your answer
Do you provide any oral health education? *
Your answer
Do you visit local schools and other organisations to provide oral health education, screening or treatments?
Your answer
Your Community
What is the population size of the community you serve? *
Your answer
What are the typical professions of the working community? *
Your answer
What is the average income? *
Your answer
How many schools are in your community? *
Your answer
How many children are in those schools? *
Your answer
What medical facilities are available in your community? *
Your answer
Are there any particular problems faced by your community? *
Your answer
Future plans for your dental programme
Ideally, what assistance would you like from Dentaid? A DentaidBox www.dentaid.org/dentaidbox , refurbished surgery equipment or other assistance? *
Your answer
How will assistance from Dentaid help improve or grow your services? *
Your answer
How many patients do you hope to treat per month with new equipment? *
Your answer
Will new equipment help you attract more support from your government or other NGO’s? *
Your answer
If you do not already provide mobile outreach dental services, how often do you hope to do this with new equipment? *
Your answer
Do you have any plans to visit local schools to provide oral health education? *
Your answer
Do you have any other plans to increase access to oral health care in your area? *
Your answer
References
Referee 1
Name *
Your answer
Email Address *
Your answer
Telephone number *
Your answer
Address *
Your answer
Position *
Your answer
Relationship to your organisation *
Your answer
Referee 2
Name *
Your answer
Email Address *
Your answer
Telephone number *
Your answer
Address *
Your answer
Position *
Your answer
Relationship to your organisation *
Your answer
Funding
Dentaid requires funding to support the manufacture of our portable dental kit and the refurbishment of second hand surgery equipment as well as the very high shipping costs from the UK.
Does your organisation have access to any funds to help cover these costs *
If you do not have your own source of funding Dentaid will endeavor to seek funding on your behalf. This will take an indefinite amount of time and will require you to provide us with good information and photos about your project to help us attract funding for you. Donors will also require feedback from you after you have received assistance.
Are you able to help with this? *
Shipping
Dentaid will arrange for the shipping of the equipment to the destination port or airport but Dentaid cannot take responsibility for any import duties, taxes or charges incurred on arrival at its destination. Dentaid cannot be held responsible for storage charges should equipment be held in customs.
Please investigate the import procedures in your location to ensure you have obtained the correct paperwork/certificates/tax exemptions that are required, before we start the shipping process. Please inform Dentaid of what paperwork you require from us in plenty of time.
Do you have access to funds to cover any import duties, taxes or charges once equipment has arrived? *
Do you have contact with a clearing agent or someone who can help with the import procedures *
Do you know of any restrictions on importing equipment to your country? Please give details. *
Your answer
Some countries are very difficult for us to send equipment due to difficult local import procedures. We can sometimes arrange shipment to a neighbouring country but if we cannot this will affect whether we are able to help you. We will let you know if this is the case.
What is your nearest international airport? *
Your answer
What is your nearest shipping port? *
Your answer
Who within your organisation will be responsible for collecting the equipment from the port or airport and for the customs clearance process? They will be the “consignee”. *
Your answer
Consignee name *
Your answer
Consignee email address *
Your answer
Consignee Mobile Number *
Your answer
Consignee Work Number *
Your answer
Consignee Home Number *
Your answer
Full address of the final destination of the equipment *
Your answer
Name and email address of your local clearing agent, if known *
Your answer
I declare that I have read, understood and agree to all of the above terms and conditions. All the information on this application form is correct. *
Required
Data Protection
Data Protection Act: Dentaid is committed to ensuring that your privacy is protected. For the purpose of volunteering with Dentaid, we ask you to provide certain information by which you can be identified. You can be assured that it will only be used in accordance with this privacy statement. The information you provide will be held in accordance with the Data Protection Act and will only used by Dentaid for your volunteering with Dentaid and will NOT be shared with any other organisation or individual unless specifically required to enable the donation to be collected.

For the purpose of the Data Protection Act, the data processor is Dentaid Ltd, The Old Sawmills, Giles Lane, Landford, Salisbury. SP5 2BG.

Agreement
Please tick the following box and fill in the date to give your agreement for Dentaid to keep you updated with our charitable work both in the UK and abroad.
Date
MM
/
DD
/
YYYY
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service