CHI Toolkit Survey Question Title * 1. What county do you live in? Abbeville Aiken Allendale Anderson Bamberg Barnwell Beaufort Berkeley Calhoun Charleston Cherokee Chester Chesterfield Clarendon Colleton Darlington Dillon Dorchester Edgefield Fairfield Florence Georgetown Greenville Greenwood Hampton Horry Jasper Kershaw Lancaster Laurens Lee Lexington Marion Marlboro McCormick Newberry Oconee Orangeburg Pickens Richland Saluda Spartanburg Sumter Union Williamsburg York Question Title * 2. My zip code is: Question Title * 3. I have this type of health care coverage: Private/Employer-Sponsored Insurance Affordable Care/ObamaCare/Marketplace Medicaid Medicare No Insurance Other If other is selected, please specify. Question Title * 4. A doctor, nurse, or healthcare provider, told me that I have the following: (Check all that apply.) High blood pressure High blood sugar (diabetes) High cholesterol None of the above Question Title * 5. My main form of transportation is: Bicycle Bus Car Taxi Walk Other If other is selected, please specify. Question Title * 6. I think these are 3 main reasons why people in our community do not seek health care: Cannot get time off Do not know where to go Hours not convenient No family doctor No insurance No one to keep children No way to get there Not sick Fear Other If other is selected, please specify. Question Title * 7. I think these are 3 main reasons that prevent people from being physically active in our community: Crime Heat/cold No community events No street lights No parks/outdoor spaces Not enough bike lanes Not enough sidewalks Personal Choice Stray dogs/animals Traffic Too tired after working Other If other is selected, please specify. Question Title * 8. I think these are 3 main reasons that prevent people in our community from eating healthy foods: Don't cook at home Eat fast food regularly No community gardens No farmer's markets No grocery stores nearby Stores don't accept SNAP/EBT/WIC Stores don't have quality produce Too expensive Too tired after work May not know how to eat healthy Other If other is selected, please specify. Question Title * 9. I think these are the 3 most important health concerns on our community: Alcohol Use Alzheimer’s/Dementia Arthritis Cancer Diabetes Drug Use Heart Disease/Stroke High Blood Pressure HIV/AIDS/STDs Infant Death Mental Health Overweight/Obesity Tobacco Use Other If other is selected, please specify. Question Title * 10. I think these are the 3 most important factors for a healthy community: Acceptance of all people Access to affordable health care Access to healthy and affordable foods Access to safe and affordable housing Access to safe places to be active Clean environment Good jobs/healthy economy Good schools Low crime Low disease rates Neighbors helping neighbors Smoke free workplace Strong faith and fellowship Other If other is selected, please specify. Question Title * 11. I would rate the overall health of our community as: Poor Fair Good Very Good Excellent Question Title * 12. I use the following tobacco products (check all that apply). I don't use tobacco products Chew tobacco, dip, snuff, snus Cigarettes Cigars or little cigars Pipes Alternative tobacco products (e-cigs, or electronic cigarettes) Other If other is selected, please specify. Question Title * 13. I agree with the idea of smoke free workplaces, including restaurants and bars. Yes No Question Title * 14. I am exposed to secondhand smoke. (i.e. smoke from someone else who may be smoking in my home, workplace, or public place.) Yes No Question Title * 15. If you are exposed to second hand smoke, where (check all that apply) Vehicle Work Home I am not exposed to second hand smoke Other If other is selected, please specify. Question Title * 16. In the last 2 days, how many fruits and vegetables have you eaten? None 1-2 3-4 5 or more Question Title * 17. In the last week, how many times were you physically active or exercised? None 1-2 3-4 5 or more Question Title * 18. How important is it to be physically active or exercise? Not important Important Extremely important Question Title * 19. How important is it to eat fruits and vegetables? Not important Important Extremely Important Question Title * 20. In the last 30 days when I bought fruits and vegetables, they were (check all that apply) Fresh Frozen Canned Can't afford to buy Other If other is selected, please specify. Question Title * 21. Age 18-25 26-39 40-54 55-64 65 or older Question Title * 22. Gender Male Female Question Title * 23. Which race/ethnic group do you most identify with? (Choose only one) White Black or African American American Indian or Alaska Native Native Hawaiian or Pacific Islander Asian More than one race Some other race Question Title * 24. Are you of Hispanic, Latino or Spanish origin? Yes No Question Title * 25. My Job Status Employed for wages Self-employed Out of work and not currently looking for word Out of work and looking for work A homemaker Student Military Retired Unable to work Question Title * 26. My household income (in $) is: Less than $25,000 $25,000-$39,999 $40,000-$59,999 $60,000-$79,999 $80,000-$99,999 $100,000 or more Question Title * 27. Highest level of education Did not finish High School High School of GED Technical College Bachelors Masters Doctorate Other, (please specify) Done