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Hello:
You are invited to participate in our Community Health Needs Survey. It will take approximately 10 minutes to complete the questionnaire.
It is very important for us to learn your honest opinions about the health of your community. Your participation in this survey is completely voluntary. Therefore, if you feel uncomfortable answering any of the questions, you can decline to answer. You can also withdraw from the survey at any point.
The information you provide will be kept anonymous. All responses will be strictly confidential and data from this process will be reported only in the aggregate. Nothing will be attributed to one person directly. If you have questions at any time about the survey or the procedures, you may contact Lorez Meinhold by email at [email protected].
Thank you very much for your time and support. Please start with the survey now by clicking on the Continue button below.
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| 1. What is your county of residence? |
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| 4. Number of family members living in the household?
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| 5. What is your current status? (Select all that apply) |
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| 6. Are you or your family members covered by health insurance? |
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| 6a. Which type of primary coverage do you have? |
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| 6b. Which type of primary coverage do members of your family have? (Select all that apply) |
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| 7. Please indicate your understanding of your health insurance coverage. |
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| 8. If uninsured, please indicate why? (Select all that apply) |
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| 9. Please select the top 3 health challenges you face: (Select only 3) |
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| 10. Please select the top 3 health challenges the community in which you live faces: (Select only 3) |
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| 11. What do you think is your community’s greatest behavioral health related need? (Rank your top 3 with 1 being the most important) |
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| Substance use including alcohol |
| | | Access to mental health services |
| | | Depression |
| | | Anxiety / Stress |
| | | Smoking and tobacco use |
| | | Suicide |
| | | Domestic abuse / violence / violence against children |
| | | Bullying |
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| 12. What keeps your family from seeking medical treatment? (Select all that apply) |
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| 13. Within the last 12 months, if you or your family members traveled outside of the region (more than 40 miles) for medical care, what services were you seeking? (Select all that apply) |
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| 14. If you or your family members obtained services outside of your region, indicate the reasons. (Select all that apply) |
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| 15. What do you need to improve the health of yourself, your family and neighbors? (Select all that apply) |
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| 16. What education / information services are needed by members of your family? (Select all that apply) |
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| 17. Where do you and your family members get most of your health information? (Select all that apply) |
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| 18. Have you had a routine physical exam in the past two years? |
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| 19. Do you believe that the kids in our community are using illegal substances (including alcohol and marijuana) to a greater or lesser degree than their peers in other communities? |
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| 20. Does the community, including the schools, provide sufficient support to parents and kids to help minimize or reduce the underage consumption of alcohol, marijuana and tobacco? |
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| 21. Any additional comments? (Limited to 100 words) | | |
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