Providence Medical Center Community Health Needs Assessment Survey

Providence Medical Center needs your help.

We are conducting a survey on the health care needs of our community. This survey will help us in our efforts to continually improve and provide services focused on the most important medical needs of our community.

Please take a few minutes to complete the following survey.

NOTE: Due to the deliberate broad distribution of this survey, you may receive more than one request to complete it. We apologize for this inconvenience and ask that you disregard any additional requests.

All responses are confidential. If you prefer not to answer certain questions for any reason please feel free to skip the question.

Thank you in advance for helping us improve the health of our community.

Question Title

* 1. Considering the QUALITY OF LIFE in your community, what is your level of agreement with...

	1 = Not at all	2	3	4	5 = A great deal	6 = Do not know
The community is a great place to live.	The community is a great place to live. 1 = Not at all	The community is a great place to live. 2	The community is a great place to live. 3	The community is a great place to live. 4	The community is a great place to live. 5 = A great deal	The community is a great place to live. 6 = Do not know
The community has a family-friendly environment.	The community has a family-friendly environment. 1 = Not at all	The community has a family-friendly environment. 2	The community has a family-friendly environment. 3	The community has a family-friendly environment. 4	The community has a family-friendly environment. 5 = A great deal	The community has a family-friendly environment. 6 = Do not know
The community has an informal, simple, "laid-back" lifestyle.	The community has an informal, simple, "laid-back" lifestyle. 1 = Not at all	The community has an informal, simple, "laid-back" lifestyle. 2	The community has an informal, simple, "laid-back" lifestyle. 3	The community has an informal, simple, "laid-back" lifestyle. 4	The community has an informal, simple, "laid-back" lifestyle. 5 = A great deal	The community has an informal, simple, "laid-back" lifestyle. 6 = Do not know
The community has a peaceful, calm, quiet environment.	The community has a peaceful, calm, quiet environment. 1 = Not at all	The community has a peaceful, calm, quiet environment. 2	The community has a peaceful, calm, quiet environment. 3	The community has a peaceful, calm, quiet environment. 4	The community has a peaceful, calm, quiet environment. 5 = A great deal	The community has a peaceful, calm, quiet environment. 6 = Do not know
The community is a "healthy" place to live.	The community is a "healthy" place to live. 1 = Not at all	The community is a "healthy" place to live. 2	The community is a "healthy" place to live. 3	The community is a "healthy" place to live. 4	The community is a "healthy" place to live. 5 = A great deal	The community is a "healthy" place to live. 6 = Do not know
The community has a sense of cultural richness.	The community has a sense of cultural richness. 1 = Not at all	The community has a sense of cultural richness. 2	The community has a sense of cultural richness. 3	The community has a sense of cultural richness. 4	The community has a sense of cultural richness. 5 = A great deal	The community has a sense of cultural richness. 6 = Do not know

Question Title

* 2. Considering the ACTIVITIES in your community, what is your level of agreement with...

	1 = Not at all	2	3	4	5 = A great deal	6 = Do not know
There are quality arts and cultural activities.	There are quality arts and cultural activities. 1 = Not at all	There are quality arts and cultural activities. 2	There are quality arts and cultural activities. 3	There are quality arts and cultural activities. 4	There are quality arts and cultural activities. 5 = A great deal	There are quality arts and cultural activities. 6 = Do not know
There are many recreational and sports activities. (e.g. outdoor recreation, parks, bike paths, and other sports and fitness activities)	There are many recreational and sports activities. (e.g. outdoor recreation, parks, bike paths, and other sports and fitness activities) 1 = Not at all	There are many recreational and sports activities. (e.g. outdoor recreation, parks, bike paths, and other sports and fitness activities) 2	There are many recreational and sports activities. (e.g. outdoor recreation, parks, bike paths, and other sports and fitness activities) 3	There are many recreational and sports activities. (e.g. outdoor recreation, parks, bike paths, and other sports and fitness activities) 4	There are many recreational and sports activities. (e.g. outdoor recreation, parks, bike paths, and other sports and fitness activities) 5 = A great deal	There are many recreational and sports activities. (e.g. outdoor recreation, parks, bike paths, and other sports and fitness activities) 6 = Do not know
There are community events and festivals.	There are community events and festivals. 1 = Not at all	There are community events and festivals. 2	There are community events and festivals. 3	There are community events and festivals. 4	There are community events and festivals. 5 = A great deal	There are community events and festivals. 6 = Do not know
There are many activities for seniors.	There are many activities for seniors. 1 = Not at all	There are many activities for seniors. 2	There are many activities for seniors. 3	There are many activities for seniors. 4	There are many activities for seniors. 5 = A great deal	There are many activities for seniors. 6 = Do not know
There are many activities for family and youth.	There are many activities for family and youth. 1 = Not at all	There are many activities for family and youth. 2	There are many activities for family and youth. 3	There are many activities for family and youth. 4	There are many activities for family and youth. 5 = A great deal	There are many activities for family and youth. 6 = Do not know

Question Title

* 3. Considering SERVICES AND RESOURCES in your community, what is your level of concern with...

	1 = not at all	2	3	4	5 = A great deal	6 = Do not know
Quality and/or cost of educational/school programs	Quality and/or cost of educational/school programs 1 = not at all	Quality and/or cost of educational/school programs 2	Quality and/or cost of educational/school programs 3	Quality and/or cost of educational/school programs 4	Quality and/or cost of educational/school programs 5 = A great deal	Quality and/or cost of educational/school programs 6 = Do not know
Resources to meet health care needs (not related to cost)	Resources to meet health care needs (not related to cost) 1 = not at all	Resources to meet health care needs (not related to cost) 2	Resources to meet health care needs (not related to cost) 3	Resources to meet health care needs (not related to cost) 4	Resources to meet health care needs (not related to cost) 5 = A great deal	Resources to meet health care needs (not related to cost) 6 = Do not know
Resources to meet mental health needs (not related to cost)	Resources to meet mental health needs (not related to cost) 1 = not at all	Resources to meet mental health needs (not related to cost) 2	Resources to meet mental health needs (not related to cost) 3	Resources to meet mental health needs (not related to cost) 4	Resources to meet mental health needs (not related to cost) 5 = A great deal	Resources to meet mental health needs (not related to cost) 6 = Do not know
Availability of youth activities	Availability of youth activities 1 = not at all	Availability of youth activities 2	Availability of youth activities 3	Availability of youth activities 4	Availability of youth activities 5 = A great deal	Availability of youth activities 6 = Do not know
Resources to meet the needs of the aging population	Resources to meet the needs of the aging population 1 = not at all	Resources to meet the needs of the aging population 2	Resources to meet the needs of the aging population 3	Resources to meet the needs of the aging population 4	Resources to meet the needs of the aging population 5 = A great deal	Resources to meet the needs of the aging population 6 = Do not know
Cost and/or availability of elder care	Cost and/or availability of elder care 1 = not at all	Cost and/or availability of elder care 2	Cost and/or availability of elder care 3	Cost and/or availability of elder care 4	Cost and/or availability of elder care 5 = A great deal	Cost and/or availability of elder care 6 = Do not know
Availability of family services	Availability of family services 1 = not at all	Availability of family services 2	Availability of family services 3	Availability of family services 4	Availability of family services 5 = A great deal	Availability of family services 6 = Do not know
Resources to meet the needs of veterans	Resources to meet the needs of veterans 1 = not at all	Resources to meet the needs of veterans 2	Resources to meet the needs of veterans 3	Resources to meet the needs of veterans 4	Resources to meet the needs of veterans 5 = A great deal	Resources to meet the needs of veterans 6 = Do not know
Resources to meet the needs of people who have mental or physical disabilities	Resources to meet the needs of people who have mental or physical disabilities 1 = not at all	Resources to meet the needs of people who have mental or physical disabilities 2	Resources to meet the needs of people who have mental or physical disabilities 3	Resources to meet the needs of people who have mental or physical disabilities 4	Resources to meet the needs of people who have mental or physical disabilities 5 = A great deal	Resources to meet the needs of people who have mental or physical disabilities 6 = Do not know

Question Title

* 4. Considering YOUTH in your community, what is your level of concern with...

	1 = Not at all	2	3	4	5 = A great deal	6 = Do not know
Changes in family composition (e.g. divorce, single parenting)	Changes in family composition (e.g. divorce, single parenting) 1 = Not at all	Changes in family composition (e.g. divorce, single parenting) 2	Changes in family composition (e.g. divorce, single parenting) 3	Changes in family composition (e.g. divorce, single parenting) 4	Changes in family composition (e.g. divorce, single parenting) 5 = A great deal	Changes in family composition (e.g. divorce, single parenting) 6 = Do not know
Youth crime	Youth crime 1 = Not at all	Youth crime 2	Youth crime 3	Youth crime 4	Youth crime 5 = A great deal	Youth crime 6 = Do not know
School drop out rates/truancy	School drop out rates/truancy 1 = Not at all	School drop out rates/truancy 2	School drop out rates/truancy 3	School drop out rates/truancy 4	School drop out rates/truancy 5 = A great deal	School drop out rates/truancy 6 = Do not know
Teen pregnancy	Teen pregnancy 1 = Not at all	Teen pregnancy 2	Teen pregnancy 3	Teen pregnancy 4	Teen pregnancy 5 = A great deal	Teen pregnancy 6 = Do not know
Bullying	Bullying 1 = Not at all	Bullying 2	Bullying 3	Bullying 4	Bullying 5 = A great deal	Bullying 6 = Do not know
Mental health	Mental health 1 = Not at all	Mental health 2	Mental health 3	Mental health 4	Mental health 5 = A great deal	Mental health 6 = Do not know
Suicide prevention	Suicide prevention 1 = Not at all	Suicide prevention 2	Suicide prevention 3	Suicide prevention 4	Suicide prevention 5 = A great deal	Suicide prevention 6 = Do not know
Teen driving	Teen driving 1 = Not at all	Teen driving 2	Teen driving 3	Teen driving 4	Teen driving 5 = A great deal	Teen driving 6 = Do not know

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* 5. Considering SAFETY in your community, what is your level of concern with...

	1 = Not at all	2	3	4	5 = A great deal	6 = Do not know
Property crimes	Property crimes 1 = Not at all	Property crimes 2	Property crimes 3	Property crimes 4	Property crimes 5 = A great deal	Property crimes 6 = Do not know
Violent crimes	Violent crimes 1 = Not at all	Violent crimes 2	Violent crimes 3	Violent crimes 4	Violent crimes 5 = A great deal	Violent crimes 6 = Do not know
Child abuse or neglect	Child abuse or neglect 1 = Not at all	Child abuse or neglect 2	Child abuse or neglect 3	Child abuse or neglect 4	Child abuse or neglect 5 = A great deal	Child abuse or neglect 6 = Do not know
Domestic violence	Domestic violence 1 = Not at all	Domestic violence 2	Domestic violence 3	Domestic violence 4	Domestic violence 5 = A great deal	Domestic violence 6 = Do not know
Substance abuse	Substance abuse 1 = Not at all	Substance abuse 2	Substance abuse 3	Substance abuse 4	Substance abuse 5 = A great deal	Substance abuse 6 = Do not know
Prostitution	Prostitution 1 = Not at all	Prostitution 2	Prostitution 3	Prostitution 4	Prostitution 5 = A great deal	Prostitution 6 = Do not know
Seatbelt use	Seatbelt use 1 = Not at all	Seatbelt use 2	Seatbelt use 3	Seatbelt use 4	Seatbelt use 5 = A great deal	Seatbelt use 6 = Do not know

Other (please specify)

Question Title

* 6. Considering ACCESS TO HEALTHCARE in your community, what is your level of concern with...

	1 = Not at all	2	3	4	5 = A great deal	6 = Do not know
Cost of healthcare	Cost of healthcare 1 = Not at all	Cost of healthcare 2	Cost of healthcare 3	Cost of healthcare 4	Cost of healthcare 5 = A great deal	Cost of healthcare 6 = Do not know
Cost of prescription drugs	Cost of prescription drugs 1 = Not at all	Cost of prescription drugs 2	Cost of prescription drugs 3	Cost of prescription drugs 4	Cost of prescription drugs 5 = A great deal	Cost of prescription drugs 6 = Do not know
Cost of health insurance	Cost of health insurance 1 = Not at all	Cost of health insurance 2	Cost of health insurance 3	Cost of health insurance 4	Cost of health insurance 5 = A great deal	Cost of health insurance 6 = Do not know
Adequate health insurance	Adequate health insurance 1 = Not at all	Adequate health insurance 2	Adequate health insurance 3	Adequate health insurance 4	Adequate health insurance 5 = A great deal	Adequate health insurance 6 = Do not know
Availability and/or cost of Dental/Vision insurance coverage	Availability and/or cost of Dental/Vision insurance coverage 1 = Not at all	Availability and/or cost of Dental/Vision insurance coverage 2	Availability and/or cost of Dental/Vision insurance coverage 3	Availability and/or cost of Dental/Vision insurance coverage 4	Availability and/or cost of Dental/Vision insurance coverage 5 = A great deal	Availability and/or cost of Dental/Vision insurance coverage 6 = Do not know
Availability and/or cost of Dental/Vision care	Availability and/or cost of Dental/Vision care 1 = Not at all	Availability and/or cost of Dental/Vision care 2	Availability and/or cost of Dental/Vision care 3	Availability and/or cost of Dental/Vision care 4	Availability and/or cost of Dental/Vision care 5 = A great deal	Availability and/or cost of Dental/Vision care 6 = Do not know
Availability of prevention programs or services	Availability of prevention programs or services 1 = Not at all	Availability of prevention programs or services 2	Availability of prevention programs or services 3	Availability of prevention programs or services 4	Availability of prevention programs or services 5 = A great deal	Availability of prevention programs or services 6 = Do not know
Availability of Primary Care Physicians (Family Doctors)	Availability of Primary Care Physicians (Family Doctors) 1 = Not at all	Availability of Primary Care Physicians (Family Doctors) 2	Availability of Primary Care Physicians (Family Doctors) 3	Availability of Primary Care Physicians (Family Doctors) 4	Availability of Primary Care Physicians (Family Doctors) 5 = A great deal	Availability of Primary Care Physicians (Family Doctors) 6 = Do not know
Availability of Specialty Care Physician services	Availability of Specialty Care Physician services 1 = Not at all	Availability of Specialty Care Physician services 2	Availability of Specialty Care Physician services 3	Availability of Specialty Care Physician services 4	Availability of Specialty Care Physician services 5 = A great deal	Availability of Specialty Care Physician services 6 = Do not know
Availability of bilingual providers/interpreters	Availability of bilingual providers/interpreters 1 = Not at all	Availability of bilingual providers/interpreters 2	Availability of bilingual providers/interpreters 3	Availability of bilingual providers/interpreters 4	Availability of bilingual providers/interpreters 5 = A great deal	Availability of bilingual providers/interpreters 6 = Do not know
Distance to healthcare services	Distance to healthcare services 1 = Not at all	Distance to healthcare services 2	Distance to healthcare services 3	Distance to healthcare services 4	Distance to healthcare services 5 = A great deal	Distance to healthcare services 6 = Do not know
Access to transportation	Access to transportation 1 = Not at all	Access to transportation 2	Access to transportation 3	Access to transportation 4	Access to transportation 5 = A great deal	Access to transportation 6 = Do not know
Confidentiality	Confidentiality 1 = Not at all	Confidentiality 2	Confidentiality 3	Confidentiality 4	Confidentiality 5 = A great deal	Confidentiality 6 = Do not know
Overuse of emergency room	Overuse of emergency room 1 = Not at all	Overuse of emergency room 2	Overuse of emergency room 3	Overuse of emergency room 4	Overuse of emergency room 5 = A great deal	Overuse of emergency room 6 = Do not know

Other (please specify)

Question Title

* 7. Considering SUBSTANCE USE/ABUSE in your community, what is your level of concern with...

	1 = Not at all	2	3	4	5 = A great deal	6 = Do not know
Illegal drug use and abuse	Illegal drug use and abuse 1 = Not at all	Illegal drug use and abuse 2	Illegal drug use and abuse 3	Illegal drug use and abuse 4	Illegal drug use and abuse 5 = A great deal	Illegal drug use and abuse 6 = Do not know
Tobacco use	Tobacco use 1 = Not at all	Tobacco use 2	Tobacco use 3	Tobacco use 4	Tobacco use 5 = A great deal	Tobacco use 6 = Do not know
Alcohol use and abuse	Alcohol use and abuse 1 = Not at all	Alcohol use and abuse 2	Alcohol use and abuse 3	Alcohol use and abuse 4	Alcohol use and abuse 5 = A great deal	Alcohol use and abuse 6 = Do not know
Abuse of prescription medications	Abuse of prescription medications 1 = Not at all	Abuse of prescription medications 2	Abuse of prescription medications 3	Abuse of prescription medications 4	Abuse of prescription medications 5 = A great deal	Abuse of prescription medications 6 = Do not know

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* 8. Considering PHYSICAL HEALTH in your community, what is your level of concern with...

	1 = Not at all	2	3	4	5 = A great deal	6 = Do not know
Obesity	Obesity 1 = Not at all	Obesity 2	Obesity 3	Obesity 4	Obesity 5 = A great deal	Obesity 6 = Do not know
Poor nutrition/eating habits	Poor nutrition/eating habits 1 = Not at all	Poor nutrition/eating habits 2	Poor nutrition/eating habits 3	Poor nutrition/eating habits 4	Poor nutrition/eating habits 5 = A great deal	Poor nutrition/eating habits 6 = Do not know
Lack of exercise and/or inactivity	Lack of exercise and/or inactivity 1 = Not at all	Lack of exercise and/or inactivity 2	Lack of exercise and/or inactivity 3	Lack of exercise and/or inactivity 4	Lack of exercise and/or inactivity 5 = A great deal	Lack of exercise and/or inactivity 6 = Do not know
Availability of exercise facilities	Availability of exercise facilities 1 = Not at all	Availability of exercise facilities 2	Availability of exercise facilities 3	Availability of exercise facilities 4	Availability of exercise facilities 5 = A great deal	Availability of exercise facilities 6 = Do not know
Cost of exercise facility	Cost of exercise facility 1 = Not at all	Cost of exercise facility 2	Cost of exercise facility 3	Cost of exercise facility 4	Cost of exercise facility 5 = A great deal	Cost of exercise facility 6 = Do not know
Availability of good walking/biking options (alternatives to driving)	Availability of good walking/biking options (alternatives to driving) 1 = Not at all	Availability of good walking/biking options (alternatives to driving) 2	Availability of good walking/biking options (alternatives to driving) 3	Availability of good walking/biking options (alternatives to driving) 4	Availability of good walking/biking options (alternatives to driving) 5 = A great deal	Availability of good walking/biking options (alternatives to driving) 6 = Do not know

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* 9. Considering MENTAL HEALTH in your community, what is your level of concern with...

	1 = Not at all	2	3	4	5 = A great deal	6 = Do not know
Depression	Depression 1 = Not at all	Depression 2	Depression 3	Depression 4	Depression 5 = A great deal	Depression 6 = Do not know
Stress	Stress 1 = Not at all	Stress 2	Stress 3	Stress 4	Stress 5 = A great deal	Stress 6 = Do not know
Availability of services for addressing mental health problems	Availability of services for addressing mental health problems 1 = Not at all	Availability of services for addressing mental health problems 2	Availability of services for addressing mental health problems 3	Availability of services for addressing mental health problems 4	Availability of services for addressing mental health problems 5 = A great deal	Availability of services for addressing mental health problems 6 = Do not know
Availability of qualified mental health providers	Availability of qualified mental health providers 1 = Not at all	Availability of qualified mental health providers 2	Availability of qualified mental health providers 3	Availability of qualified mental health providers 4	Availability of qualified mental health providers 5 = A great deal	Availability of qualified mental health providers 6 = Do not know

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* 10. Considering ILLNESS in your community, what is your level of concern with...

	1 = Not at all	2	3	4	5 = A great deal	6 = Do not know
Cancer	Cancer 1 = Not at all	Cancer 2	Cancer 3	Cancer 4	Cancer 5 = A great deal	Cancer 6 = Do not know
Chronic disease (e.g. diabetes, heart disease, multiple sclerosis)	Chronic disease (e.g. diabetes, heart disease, multiple sclerosis) 1 = Not at all	Chronic disease (e.g. diabetes, heart disease, multiple sclerosis) 2	Chronic disease (e.g. diabetes, heart disease, multiple sclerosis) 3	Chronic disease (e.g. diabetes, heart disease, multiple sclerosis) 4	Chronic disease (e.g. diabetes, heart disease, multiple sclerosis) 5 = A great deal	Chronic disease (e.g. diabetes, heart disease, multiple sclerosis) 6 = Do not know
Communicable disease (e.g. sexually transmitted diseases, AIDS)	Communicable disease (e.g. sexually transmitted diseases, AIDS) 1 = Not at all	Communicable disease (e.g. sexually transmitted diseases, AIDS) 2	Communicable disease (e.g. sexually transmitted diseases, AIDS) 3	Communicable disease (e.g. sexually transmitted diseases, AIDS) 4	Communicable disease (e.g. sexually transmitted diseases, AIDS) 5 = A great deal	Communicable disease (e.g. sexually transmitted diseases, AIDS) 6 = Do not know

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* 11. Listed below are some general health conditions/diseases. Please check all that apply to you.

Arthritis

Asthma

Cancer

Depression, Anxiety, Stress, Etc.

Demetria / Alzheimer's disease

Diabetes

Muscles or bones (e.g. back problems or broken bones)

Heart conditions (e.g. congestive heart failure)

High cholesterol

High blood pressure

Female health issues

Weight control

None

Other (please specify)

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* 12. What additional Health and Wellness concerns do you have about your community that are not reflected in the previous questions?

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* 13. Do you have heath care concerns especially related to children 18 years of age or younger? If so, what are they?

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* 14. From the perspective of delivery of health care, how well do you feel the following topics are being addressed

	1 = Not very well	2	3	4	5 = Very well	6 = Do not know
Health Services for obesity	Health Services for obesity 1 = Not very well	Health Services for obesity 2	Health Services for obesity 3	Health Services for obesity 4	Health Services for obesity 5 = Very well	Health Services for obesity 6 = Do not know
Health Services for diabetes	Health Services for diabetes 1 = Not very well	Health Services for diabetes 2	Health Services for diabetes 3	Health Services for diabetes 4	Health Services for diabetes 5 = Very well	Health Services for diabetes 6 = Do not know
Health Services for cancer patients	Health Services for cancer patients 1 = Not very well	Health Services for cancer patients 2	Health Services for cancer patients 3	Health Services for cancer patients 4	Health Services for cancer patients 5 = Very well	Health Services for cancer patients 6 = Do not know
Health Services for heart disease	Health Services for heart disease 1 = Not very well	Health Services for heart disease 2	Health Services for heart disease 3	Health Services for heart disease 4	Health Services for heart disease 5 = Very well	Health Services for heart disease 6 = Do not know
Mental health services (e.g depression, dementia, Alzheimer's disease, stress)	Mental health services (e.g depression, dementia, Alzheimer's disease, stress) 1 = Not very well	Mental health services (e.g depression, dementia, Alzheimer's disease, stress) 2	Mental health services (e.g depression, dementia, Alzheimer's disease, stress) 3	Mental health services (e.g depression, dementia, Alzheimer's disease, stress) 4	Mental health services (e.g depression, dementia, Alzheimer's disease, stress) 5 = Very well	Mental health services (e.g depression, dementia, Alzheimer's disease, stress) 6 = Do not know
Cost of the delivery of health care	Cost of the delivery of health care 1 = Not very well	Cost of the delivery of health care 2	Cost of the delivery of health care 3	Cost of the delivery of health care 4	Cost of the delivery of health care 5 = Very well	Cost of the delivery of health care 6 = Do not know
Access to emergency services (e.g. ambulance and 911)	Access to emergency services (e.g. ambulance and 911) 1 = Not very well	Access to emergency services (e.g. ambulance and 911) 2	Access to emergency services (e.g. ambulance and 911) 3	Access to emergency services (e.g. ambulance and 911) 4	Access to emergency services (e.g. ambulance and 911) 5 = Very well	Access to emergency services (e.g. ambulance and 911) 6 = Do not know
Attention given to preventative services	Attention given to preventative services 1 = Not very well	Attention given to preventative services 2	Attention given to preventative services 3	Attention given to preventative services 4	Attention given to preventative services 5 = Very well	Attention given to preventative services 6 = Do not know
Distance/transportation to health care facilities	Distance/transportation to health care facilities 1 = Not very well	Distance/transportation to health care facilities 2	Distance/transportation to health care facilities 3	Distance/transportation to health care facilities 4	Distance/transportation to health care facilities 5 = Very well	Distance/transportation to health care facilities 6 = Do not know
Number of health care providers and specialists	Number of health care providers and specialists 1 = Not very well	Number of health care providers and specialists 2	Number of health care providers and specialists 3	Number of health care providers and specialists 4	Number of health care providers and specialists 5 = Very well	Number of health care providers and specialists 6 = Do not know
Coordination/communication among providers	Coordination/communication among providers 1 = Not very well	Coordination/communication among providers 2	Coordination/communication among providers 3	Coordination/communication among providers 4	Coordination/communication among providers 5 = Very well	Coordination/communication among providers 6 = Do not know

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* 15. In your opinion, which of the health care concerns listed above is the most important and why?

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* 16. What specific heath services, if any, do you think your community needs to add, and why?

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* 17. Have you personally had any of the following types of health screenings or care in the past year? (choose all that apply)

Cancer (of any kind)

Cardiac (heart attack risk factors)

Vascular (stroke or blood clotting)

Diabetes

Other (please specify)

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* 18. What problems do you have that might keep you from going to the doctor when needed?

Transportation

Work Hours

Doesn’t speak the same language

No time

Clinic hours

The expense

No health insurance

No phone

Not able to find a doctor/dentist

Forget to make or keep doctor visits

Other (please specify)

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* 19. Which hospital do you use for your health care services? (Facility name and city)

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* 20. Why did you choose the hospital above for health care services?

Influenced by health insurance

Location

Quality of Services

Reputation of medical providers

Sense of being valued as a patient

Scope of Services

Other (please specify)

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* 21. What is your zip code?

Allen - 68710

Carroll - 68723

Coleridge - 68727

Concord - 68728

Dixon - 68732

Emerson - 68733

Hartington - 68739

Laurel - 68745

Pilger - 68768

Randolph - 68771

Wakefield - 68784

Wayne - 68787

Winside - 68790

Wisner - 68791

Other (please specify)

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* 22. How can Providence Medical Center improve our services?

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* 23. What is your age?

18 to 24 years

25 to 34 years

35 to 44 years

45 to 54 years

55 to 59 years

60 to 64 years

65 years and older

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* 24. What is your gender?

Male

Female

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* 25. What is your area of employment (Choose all that apply)

Health Care

Human Services

Retail Trade

Educational services

Arts/ Entertainment

Agriculture

Construction

Government

Manufacturing

Not applicable

Other (please specify)

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* 26. Over the past 12 months how have you paid for health care costs for you or your family? (Choose all that apply)

Health insurance through an employer

Private health insurance

Personal income (e.g. cash, check, or credit card)

Medicaid

Medicare

Military

Veteran's health care benefits

Did not access health care in the last 12 months

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* 1. Considering the QUALITY OF LIFE in your community, what is your level of agreement with...

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* 2. Considering the ACTIVITIES in your community, what is your level of agreement with...

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* 3. Considering SERVICES AND RESOURCES in your community, what is your level of concern with...

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* 4. Considering YOUTH in your community, what is your level of concern with...

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* 5. Considering SAFETY in your community, what is your level of concern with...

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* 6. Considering ACCESS TO HEALTHCARE in your community, what is your level of concern with...

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* 7. Considering SUBSTANCE USE/ABUSE in your community, what is your level of concern with...

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* 8. Considering PHYSICAL HEALTH in your community, what is your level of concern with...

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* 9. Considering MENTAL HEALTH in your community, what is your level of concern with...

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* 10. Considering ILLNESS in your community, what is your level of concern with...

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* 11. Listed below are some general health conditions/diseases. Please check all that apply to you.

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* 12. What additional Health and Wellness concerns do you have about your community that are not reflected in the previous questions?

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* 13. Do you have heath care concerns especially related to children 18 years of age or younger? If so, what are they?

Question Title

* 14. From the perspective of delivery of health care, how well do you feel the following topics are being addressed

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* 15. In your opinion, which of the health care concerns listed above is the most important and why?

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* 16. What specific heath services, if any, do you think your community needs to add, and why?

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* 17. Have you personally had any of the following types of health screenings or care in the past year? (choose all that apply)

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* 18. What problems do you have that might keep you from going to the doctor when needed?

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* 19. Which hospital do you use for your health care services? (Facility name and city)

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* 20. Why did you choose the hospital above for health care services?

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* 21. What is your zip code?

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* 22. How can Providence Medical Center improve our services?

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* 23. What is your age?

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* 24. What is your gender?

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* 25. What is your area of employment (Choose all that apply)

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* 26. Over the past 12 months how have you paid for health care costs for you or your family? (Choose all that apply)

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* 27. Please share any additional concerns or suggestions you have about local health care needs and services.