Annual Survey State(Required)AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingParent Organization(Required)Coalition Name(Required)Executive Director Name(Required)Executive Director TitleExecutive Director Email(Required) Executive Director Phone(Required)Coalition Address(Required) Street Address Address Line 2 City State ZIP / Postal Code Facebook URL X URL (Twitter) Year Established(Required)Coalition Website(Required) Mission Statement(Required)Policy Focus and Program InitiativesCurrent Priorities(Required) Perinatal (e.g., coverage, access, financing) Children (e.g., coverage, access, financing) Adults (e.g., coverage, access, financing) Aging Population (e.g., coverage, access, financing) Public Education Surveillance/Data Collection Early Childhood Caries Periodontal Disease Oral Cancer Infection Control Injury Water Fluoridation Dental Sealants Fluoride Varnish School-Based Dental Care Tobacco Prevention/Cessation Expansion of Safety Net New Workforce Models Scope of Practice Implementation of Healthcare Reform Medical/Dental Integration Medicaid State Oral Health/Public Health Programs Other Please Specify(Required)With which state government entities does your coalition work regularly?(Required) State Legislature Governor's Office Health Department State Oral Health Program Medicaid/CHIP Program Other Please specify(Required)Does your coalition engage in lobbying?(Required) Yes No If Yes(Required)DirectGrassrootsBothBudgetary InfoIs your state CDC-funded?(Required) Yes No Is your coalition funded by your state's CDC grant?(Required) Yes No Does your coalition use an outside fiscal agent?(Required) Yes No Does your coalition have a fund-development plan?(Required) Yes No Are you willing to share your fund-development plan with other coalitions?(Required) Yes No Size of annual operating budget(Required)$500K and higher: $1,500$350K - $400K: $1,000$250K - $349K: $700$125K - $249K: $500$50K - $124K: $350$49K - and under: $200Does your organization conduct a:(Required) Full Financial Audit Financial Review Neither RevenueList revenue percentages or "0" if not applicable. Grants(Required)Please enter a number from 0 to 100.Individual Donations(Required)Please enter a number from 0 to 100.Corporate Sponsorships(Required)Please enter a number from 0 to 100.Programs/Events(Required)Please enter a number from 0 to 100.ExpensesList expense percentages or "0" if not applicablePrograms/Events(Required)Please enter a number from 0 to 100.Administration(Required)Please enter a number from 0 to 100.Fundraising(Required)Please enter a number from 0 to 100.Coalition StructureTax Structure(Required)501(c)3501(c)4No Formal Tax StatusIf your coalition is a 501(c)3, has the coalition made a 501(h) election with the IRS?(Required) Yes No Paid Full-Time Staff(Required)Paid Part-Time Staff(Required)Contract Employees?(Required) Yes No Contract Type(Required)Number of Volunteers(Required)Do you offer benefits to your paid staff?(Required) Yes No Upload Bylaws(Please avoid commas in filename)Max. file size: 128 MB. Does your coalition have committees?(Required) Yes No Committees List(Required)Does your coalition have affiliated regional coalitions?(Required) Yes No Does your coalition have a membership?(Required) Yes No Membership Dues?(Required) Yes No Number of Individual Members(Required)Number of Organizational Members(Required)Do members have voting rights?(Required) Yes No Is membership open to anyone?(Required) Yes No Does your coalition have a membership application or criteria document?(Required) Yes No Upload Member Application Document(Please avoid commas in filename)Max. file size: 128 MB. PlanningDoes your coalition have a strategic plan?(Required) Yes No Upload Strategic Plan(Please avoid commas in filename)Max. file size: 128 MB. Does your coalition have a state advocacy plan or legislative action agenda?(Required) Yes No Upload Advocacy/Legislative Plan(Please avoid commas in filename)Max. file size: 128 MB. Does your state have a state oral health plan?(Required) Yes No Upload State Oral Health Plan(Please avoid commas in filename)Max. file size: 128 MB. Is your coalition a driver (i.e. developing and monitoring implementation) of the state oral health plan?(Required) Yes No Communications and ActivitiesTypes of communications modalities(Required) Press Releases Paper Newsletter Electronic Newsletter or Update Webinars In-Person Events EvaluationDoes your coalition have a formal evaluation plan?(Required) Yes No Upload Evaluation Plan(Please avoid commas in filename)Max. file size: 128 MB.
