Dental Survey 2010
Name: 


  1. Practice Name


  1. Contact Person


  1. Email Address (user@domain.com)


  1. Mailing Address


  1. City


  1. State


  1. Zip


  1. Telephone


  1. Fax


  1. Location your office is closest to:
    Madison
    Milwaukee
    Fox Cities


  1. How would you like to receive the survey results?
    Email
    Paper Copy


  1. If requesting Email copy, please provide the Email address you would like the results sent to.


  1. If requesting paper copy, please indicate the address at which you would like to receive it.


  1. Receptionist # 1: Years with Practice
    <3
    3 to 7
    >7


  1. Receptionist #1: Hourly Rate


  1. If NOT HOURLY Other Wage Methods e.g., salaried (list annual salary), commission (indicate method)


  1. Receptionist # 2: Years with Practice
    <3
    3 to 7
    >7


  1. Receptionist #2: Hourly Rate


  1. If NOT HOURLY Other Wage Methods e.g., salaried (list annual salary), commission (indicate method)


  1. Receptionist #3: Years with Practice
    <3
    3 to 7
    >7


  1. Receptionist #3: Hourly Rate


  1. If NOT HOURLY Other Wage Methods e.g., salaried (list annual salary), commission (indicate method)


  1. Office/Business Manager #1: Years with Practice
    <3
    3 to 7
    >7


  1. Office/Business Manager #1: Hourly Rate


  1. If NOT HOURLY Other Wage Methods e.g., salaried (list annual salary), commission (indicate method)


  1. Office Asst/File Clerk #1: Years with Practice
    <3
    3 to 7
    >7


  1. Office Asst/File Clerk #1: Hourly Rate


  1. If NOT HOURLY Other Wage Methods e.g., salaried (list annual salary), commission (indicate method)


  1. Office Asst/File Clerk #2: Years with Practice
    <3
    3 to 7
    >7


  1. Office Asst/File Clerk #2: Hourly Rate


  1. If NOT HOURLY Other Wage Methods e.g., salaried (list annual salary), commission (indicate method)


  1. Billing Clerk #1: Years with Practice
    <3
    3 to 7
    >7


  1. Billing Clerk #1: Hourly Rate


  1. If NOT HOURLY Other Wage Methods e.g., salaried (list annual salary), commission (indicate method)


  1. Billing Clerk #2: Years with Practice
    <3
    3 to 7
    >7


  1. Billing Clerk #2: Hourly Rate


  1. If NOT HOURLY Other Wage Methods e.g., salaried (list annual salary), commission (indicate method)


  1. Dental Hygienist #1: Years with Practice
    <3
    3 to 7
    >7


  1. Dental Hygienist #1: Hourly Rate


  1. If NOT HOURLY Other Wage Methods e.g., salaried (list annual salary), commission (indicate method)


  1. Dental Hygienist #2: Years with Practice
    <3
    3 to 7
    >7


  1. Dental Hygienist #2: Hourly Rate


  1. If NOT HOURLY Other Wage Methods e.g., salaried (list annual salary), commission (indicate method)


  1. Dental Hygienist #3: Years with Practice
    <3
    3 to 7
    >7


  1. Dental Hygienist #3: Hourly Rate


  1. If NOT HOURLY Other Wage Methods e.g., salaried (list annual salary), commission (indicate method)


  1. Dental Hygienist #4: Years with Practice
    <3
    3 to 7
    >7


  1. Dental Hygienist #4: Hourly Rate


  1. If NOT HOURLY Other Wage Methods e.g., salaried (list annual salary), commission (indicate method)


  1. Dental Hygienist #5: Years with Practice
    <3
    3 to 7
    >7


  1. Dental Hygienist #5: Hourly Rate


  1. If NOT HOURLY Other Wage Methods e.g., salaried (list annual salary), commission (indicate method)


  1. Dental Hygienist #6: Years with Practice
    <3
    3 to 7
    >7


  1. Dental Hygienist #6 Hourly Rate


  1. If NOT HOURLY Other Wage Methods e.g., salaried (list annual salary), commission (indicate method)


  1. Dental Hygienist #7: Years with Practice
    <3
    3 to 7
    >7


  1. Dental Hygienist #7 Hourly Rate


  1. If NOT HOURLY Other Wage Methods e.g., salaried (list annual salary), commission (indicated method)


  1. Dental Hygienist #8: Years with Practice
    <3
    3 to 7
    >7


  1. Dental Hygienist #8 Hourly Rate


  1. If NOT HOURLY Other Wage Methods e.g., salaried (list annual salary), commission (indicate method)


  1. Dental Assistant #1: Years with Practice
    <3
    3 to 7
    >7


  1. Dental Assistant #1: Hourly Rate


  1. If NOT HOURLY Other Wage Methods e.g., salaried (list annual salary), commission (indicate method)


  1. Dental Assistant #2: Years with Practice
    <3
    3 to 7
    >7


  1. Dental Assistant #2: Hourly Rate


  1. If NOT HOURLY Other Wage Methods e.g., salaried (list annual salary), commission (indicate method)


  1. Dental Assistant #3: Years with Practice
    <3
    3 to 7
    >7


  1. Dental Assistant #3: Hourly Rate


  1. If NOT HOURLY Other Wage Methods e.g., salaried (list annual salary), commission (indicate method)


  1. Dental Assistant #4: Years with Practice
    <3
    3 to 7
    >7


  1. Dental Assistant #4: Hourly Rate


  1. If NOT HOURLY Other Wage Methods e.g., salaried (list annual salary), commission (indicate method)


  1. Dental Assistant #5: Years with Practice
    <3
    3 to 7
    >7


  1. Dental Assistant #5: Hourly Rate


  1. If NOT HOURLY Other Wage Methods e.g., salaried (list annual salary), commission (indicated method)


  1. Dental Assistant #6: Years with Practice
    <3
    3 to 7
    >7


  1. Dental Assistant #6 Hourly Rate


  1. If NOT HOURLY Other Wage Methods e.g., salaried (list annual salary), commission (indicate method)


  1. Dental Assistant #7: Years with Practice
    <3
    3 to 7
    7


  1. Dental Assistant #7 Hourly Rate


  1. If NOT HOURLY Other Wage Methods e.g., salaried (list annual salary), commission (indicate method)


  1. "Position #1": Title or description of position


  1. "Position #1": Years with Practice
    <3
    3 to 7
    >7


  1. "Position #1": Hourly Rate


  1. If NOT HOURLY Other Wage Methods e.g., salaried (list annual salary), commission (indicated method)


  1. "Position #2": Title or description of position


  1. "Position #2": Years with Practice
    <3
    3 to 7
    >7


  1. "Position #2": Hourly Rate


  1. If NOT HOURLY Other Wage Methods e.g., salaried (list annual salary), commission (indicated method)


  1. "Position #3": Title or description of position


  1. "Position #3": Years with Practice
    <3
    3 to 7
    >7


  1. "Position #3": Hourly Rate


  1. If NOT HOURLY Other Wage Methods e.g., salaried (list annual salary), commission (indicated method)


  1. Employee Raises

    What range of wage increases do you anticipate giving this year?

    Lowest%


  1. Highest %


  1. Associate Salaries

    Associate #1: Specialty (i.e., general dentist, periodontist, orthodontist, etc.)


  1. Associate #1: Years with Practice
    <3
    3 to 7
    >7


  1. Please only answer one question from 99-102 regarding how salary is paid. (Base Salary OR Fixed Percentage OR Hourly).

    Also answer "specialty," "Years with practice" and "Bonus Received,"

    If Base Salary Guaranteed (Not including bonus)


  1. If Fixed Percentage with a guaranteed base salary (please indicate what the percentage is for)


  1. If Hourly Wage if no base is guaranteed


  1. Bonus Received (if dollar amount, please indicate how bonus is determined)


  1. Associate #2: Specialty (i.e., general dentist, periodontist, orthodontist, etc.)


  1. Associate #2: Years with Practice
    <3
    3 to 7
    >7


  1. Please only answer one question from 105-108 regarding how salary is paid. (Base Salary OR Fixed Percentage OR Hourly).

    Also answer "specialty," "Years with practice" and "Bonus Received,"

    If Base Salary Guaranteed (Not including bonus)


  1. If Fixed Percentage with a guaranteed base salary (please indicate what the percentage is for)


  1. If Hourly Wage if no base is guaranteed


  1. Bonus Received (if dollar amount, please indicate how bonus is determined)


  1. Associate #3: Specialty (i.e., general dentist, periodontist, orthodontist, etc.)


  1. Associate #3: Years with Practice
    <3
    3 to 7
    >7


  1. Please only answer one question from 111-114 regarding how salary is paid. (Base Salary OR Fixed Percentage OR Hourly).

    Also answer "specialty," "Years with practice" and "Bonus Received,"

    If Base Salary Guaranteed (Not including bonus)


  1. If Fixed Percentage with a guaranteed base salary (please indicate what the percentage is for)


  1. If Hourly Wage if no base is guaranteed


  1. Bonus Received (if dollar amount, please indicate how bonus is determined)


  1. Associate #4: Specialty (i.e., general dentist, periodontist, orthodontist, etc.)


  1. Associate #4: Years with Practice
    <3
    3 to 7
    >7


  1. Please only answer one question from 117-120 regarding how salary is paid. (Base Salary OR Fixed Percentage OR Hourly).

    Also answer "specialty," "Years with practice" and "Bonus Received,"

    If Base Salary Guaranteed (Not including bonus)


  1. If Fixed Percentage with a guaranteed base salary


  1. If Hourly Wage if no base is guaranteed


  1. Bonus Received (if dollar amount, please indicate how bonus is determined)


  1. Associate Raises

    What range of wage increases do you anticipate giving this year?

    Lowest %


  1. Highest %


  1. What is the compensation formula of an Associate, including how is lab expense handled?


  1. Benefits Survey Please fill out your office's benefit information, basing your answers on full-time employees unless otherwise indicated.

    Group Medical Insurance _______________________________________________________

    A1. What portion of the health premium does the clinic pay for employees (single coverage)? (Please complete either A OR B).

    A. Percentage of Premium
    1% - 25%
    26% - 50%
    51% - 75%
    76% - 100%
    None: Employee pays 100%


  1. B. OR specific dollar amount?


  1. A2. Is medical insurance available for employee's spouse and dependents?
    Yes
    No


  1. B. OR specific dollar amount?


  1. A3. If YES, what portion does the clinic pay for spouse and dependents? (Please complete either A OR B).

    A. Percentage of Premium
    1% - 25%
    26% - 50%
    51% - 75%
    76% - 100%
    None: Employee pays 100%


  1. A4. Does length of employment change amount of premium paid by clinic?
    Yes
    No


  1. A5. If YES, please describe change.


  1. Flex Time Off (FTO or PTO)/Vacation/Sick Leave _______________________________________________________

    Flex Time off (FTO) or Paid Time Off (PTO) is a time off package where the vacation, sick leave, personal and floating day policies have been combined into one policy where days may be used for vacation, personal time, illness or time off to care for dependents.

    FLEX TIME OFF (FTO - also known as PTO or ETO)

    B1. Do you offer FTO instead of traditional sick and vacation time?
    Yes
    No


  1. B2. What is the length of service required to earn the following FTO benefits?

    If time is received upon start date, please enter "start date" under that amount.

    FTO: 1 week


  1. FTO: 2 weeks


  1. FTO: 3 weeks


  1. FTO: 4 weeks


  1. FTO: 5 weeks


  1. FTO: 6 weeks


  1. B3. How many days does an employee have to be employed before he or she can use any FTO?


  1. B4. How is FTO earned?
    Hourly
    Weekly
    Monthly
    Lump sum date of hire
    Lump sum start of year
    Other


  1. B5. Can FTO be carried over at the end of the year?
    Yes
    No


  1. B6. If YES, what is the maximum amount of FTO hours that can be carried over into a new year?


  1. B7. Do you pay any unused FTO at year-end?
    Yes
    No


  1. B8. If so, what is the method?


  1. B9. Please describe your FTO policy and note any difference among employees.


  1. VACATION - If you filled out the above FTO section, please skip this section. If not, please proceed.

    C1. For offices NOT using FTO, do you offer vacation time?
    Yes
    No


  1. C2. What is the length of service required to earn the following vacation benefits?

    If time is received upon start date, please enter "start date" under that amount.

    Vacation: 1 week


  1. Vacation: 2 weeks


  1. Vacation: 3 weeks


  1. Vacation: 4 weeks


  1. Vacation: 5 weeks


  1. Vacation: 6 weeks


  1. C3. How long does an employee have to be employed before he or she can use this vacation?


  1. C4. How is vacation earned?
    Hourly
    Weekly
    Monthly
    Lump sum date of hire
    Lump sum start of year
    Other


  1. C5. Can vacation be carried over from one year to another?
    Yes
    No


  1. C6. How much vacation do you require employees to take during the dentist's vacation?
    All
    A Portion
    None (Not required)


  1. SICK LEAVE - If you filled out the above FTO section, please skip this section. If not, please proceed.

    D1. For the office not using FTO, is a sick leave program offered to employees?
    Yes
    No


  1. D2. How many hours per year of sick time do full-time employees accrue?


  1. D3. Can sick leave be carried over from year to year
    Yes
    No


  1. D4. If YES, what is the maximum amount of sick leave hours that can be carried over?


  1. D5. Do you pay unused sick leave at year-end?
    Yes
    No


  1. D6. If YES, what is the method?
    10% of unused at regular rate
    50% of unused at regular rate
    100% of unused at regular rate
    Other:


  1. D7. Do you pay unused sick leave upon separation or termination?
    Yes
    No


  1. D8. What incentives do you offer to reward good attendance? (Check all that apply).
    Additional pay
    Additional time off
    None
    Other:


  1. D9. Additional comments about your sick leave program:


  1. Paid Holidays _______________________________________________________

    E1. For the offices using FTO, are paid holidays included in FTO time?
    Yes
    No


  1. E2. For all offices, please check the PAID holidays observed: (Check all that apply).
    New Year's Eve
    New Year's Day
    Memorial Day
    4th of July
    Labor Day
    Thanksgiving Day
    Thanksgiving Friday
    Christmas Eve
    Christmas Day
    Personal/Floating
    Other:


  1. Retirement Plan _______________________________________________________

    F1. Does your practice offer a retirement plan for employees?
    Yes
    No


  1. F2. If YES, what plan(s) do you offer? (Check all that apply).
    Profit Sharing without 401(k)
    401(k) Profit Sharing
    Age-Weighted Profit Sharing Plan
    Cross Tested
    Money Purchase Pension Plan
    "SIMPLE" IRA or 401(k) Plan
    Simplified Employee Pension (SEP)
    Defined Benefit
    Other


  1. 401(k) Plans - Answer only if you offer a 401(k) plan

    F3. What is the length of employment required to be eligible in the 401(k) plan?


  1. F4. Do you offer a match for your 401(k) plan?
    Yes
    No


  1. F5. If YES, what is the formula?


  1. F6. What is the maximum match percentage?


  1. Non-401(k) Plans - Answer if you offer plan(s) other than 401(k)

    F7. What is the length of service required for non-401(k) plans?


  1. F8. What is the annual "employer contribution," as a percentage of the employee's wages to his or her retirement plan? (Please do not include any employee contributions in your response).


  1. Flexible Spending Account (Cafeteria Plan) _______________________________________________________

    G1. Does your practice offer a Flexible Spending Account (Cafeteria Plan)?
    Yes
    No


  1. G2. If YES, which of the following is offered? (Check all that apply).
    Medical Insurance Premium
    Medical Expenses
    Dependent Care
    Other


  1. Health Reimbursement Account (HRA) _______________________________________________________

    H1. Does your practice offer a Health Reimbursement Account (HRA)?
    Yes
    No


  1. H2. What is the monthly employer dollar amount contribution to the HRA?


  1. Dental Benefits _______________________________________________________

    I1. Do you provide dental insurance for employees?
    Yes
    No


  1. I2. What portion of the dental insurance premium does the clinic pay for employees (single coverage)? (Please complete either A OR B).

    A. Percentage of Premium
    1% - 25%
    26% - 50%
    51% - 75%
    76% - 100%
    None: Employee pays 100%


  1. B. OR specific dollar amount?


  1. I3. Is free dental care provided to employees?
    Yes
    No


  1. I4. If YES, does the patient pay for lab fees?
    Yes
    No


  1. I5. Is there a dollar maximum for free care provided?
    Yes
    No


  1. I6. If YES, what is the dollar amount?


  1. I8. What is the dollar amount provided for employee relatives?


  1. I7. Who else, related to the employee, is free dental care provided for? (Check all that apply)
    Spouse
    Children
    Other family members
    Other


  1. Uniforms _______________________________________________________

    J1. How does your practice handle uniforms?
    Employee provides
    Complete uniform is provided in full
    Uniform allowance is given at a set dollar amount
    Cost is shared without a set dollar amount


  1. J2. If you provide a uniform allowance, what dollar amount is given?


  1. J3. If cost is shared, what is the arrangement?


  1. Continuing Education _______________________________________________________

    K1. Do you pay for continuing education for hygienists?
    Yes
    No


  1. K2. Is there a dollar amount maximum for continuing education?
    Yes
    No


  1. K3. If YES, what is the dollar amount maximum?


  1. Misc. _______________________________________________________

    L1. Please list any additional benefits you provide that are not covered in this survey.


  1. Part-time Employees _______________________________________________________

    M1. Does your practice have regular part-time employees?
    Yes
    No


  1. M2. Do part-time employees receive benefits?
    Yes
    No


  1. M3. If YES, how many hours per week must they work to receive benefits?


  1. M4. If YES, please fill in the following grid describing benefits they receive: Group Medical Insurance
    Same as full-time employees
    Prorated
    Not offered


  1. FTO
    Same as full-time employees
    Prorated
    Not offered


  1. Paid Holidays
    Same as full-time employees
    Prorated
    Not offered


  1. Sick Leave
    Same as full-time employees
    Prorated
    Not offered


  1. Vacation
    Same as full-time employees
    Prorated
    Not offered


  1. Retirement Plan
    Same as full-time employees
    Prorated
    Not offered


  1. Flexible Spending Account
    Same as full-time employees
    Prorated
    Not offered


  1. Health Reimbursement Account
    Same as full-time employees
    Prorated
    Not offered


  1. Uniforms
    Same as full-time employees
    Prorated
    Not offered


  1. Do you attend the WDA annual convention?
    Yes
    No


  1. Dental Benefits
    Same as full-time employees
    Prorated
    Not offered


  1. If yes, which locations?
    Milwaukee
    Wisconsin Dells
    Green Bay


  1. Do you attend the Chicago Dental Society Midwinter meeting?
    Yes
    No


  1. Please send me additional information
    Yes
    No


  1. Suggestions for improving our survey





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