Burlington County Community Health & Quality of Life Survey

Please take a few minutes to complete the survey below. The Burlington County Health Department is seeking your opinion about the quality of life in your community and ways to improve upon it. Survey results, along with other data, will be used to revise the county-wide Community Health Improvement Plan. All responses are strictly confidential and participation is voluntary. We thank you for your support in helping to improve our county. Any questions about the survey can be directed to John Sivon at 609-265-5467.

Question Title

* 1. Please choose the things that would "most improve" the quality of life in your community.
Select All That Apply

A) Access to Health Care (e.g., family doctor, dental care, counseling and mental health)

B) Affordable Health Insurance (e.g., medical, dental and prescription)

C) Activities for Youth

D) Affordable Housing

E) Arts and Cultural Events

F) Clean Environment

G) Communication and Information Referral

H) Cultural Diversity

I) Emergency Preparedness

J) Excellent Race Relations

K) Good Schools

L) Healthy Behaviors and Lifestyles

M) Local Jobs and Healthy Economy

N) Low Crime/Safe Neighborhoods

O) Low Adult Death and Disease Rates

P) Low Infant Deaths

Q) Low Level of Child Abuse

R) Parks and Recreation

S) Public Transportation

T) Religious and Spiritual Values

U) Support System (e.g., family,friends,neighbors,services)

V) Technology/Computers

Other (please specify)

Question Title

* 2. From your selections above, please rank the top 3 things that would improve quality of life:

Question Title

* 3. Please choose the major “health problems” that have the "greatest impact" on overall health in your community.
Select All That Apply

A) Aging Problems (e.g.,arthritis, hearing/vision loss etc.)

B) Cancers

C) Child Abuse/Neglect

D) Dental Problems

E) Diabetes

F) Domestic Violence

G) Firearm (gun)-Related Injuries

H) Farming-Related Injuries

I) Heart Disease and Stroke

J) High Blood Pressure

K) HIV/AIDS

L) Homicide

M) Infant Death Infectious Disease (Diseases that are from person to person like hepatitis, TB, flu etc.)

N) Mental Health

O) Motor Vehicle Crash Injuries

P) Rape/Sexual Assault

Q) Respiratory/Lung Disease

R) Smoking/Second Hand Smoke

S) Stress

T) Suicide

U) Teen Violence/Bullying/Gang Activity

V) Teenage Pregnancy

W) Terrorist Activities

X) Uncontrolled Anger/Road Rage

Y) Unsecured Firearms (guns)

Other (please specify)

Question Title

* 4. From your selections above, please rank the top 3 things that you would consider as major “health problems”:

Question Title

* 5. Please choose the major “risky behaviors” that have the "greatest impact" on overall health in your community.
Select All That Apply

A) Alcohol Abuse

B) Apathy/Lack of Motivation

C) Being Overweight

D) Child Abuse/Neglect

E) Divorce/Separation

F) Domestic Violence

G) Dropping Out of School

H) Drug Abuse

I) Homelessness

J) Lack Of Exercise

K) Lack of Health Care

L) Lack of Maternity Care

M) Monetary Issues (e.g., overspending, gambling, debt)

N) Not Getting “Shots” to Prevent Disease

O) Poor Eating Habits

P) Racism

Q) Teen Violence/Bullying/Gang Activity

R) Tobacco Use

S) Not Using Birth Control

T) Not Using Seat Belts/Child Safety Seats

U) Unsafe Sex

Other (please specify)

Question Title

* 6. From your selections above, please rank the top 3 things that you would consider as major "risky behaviors":

Now that we have obtained your views on ways to improve the health of your community, please take a few minutes and tell us about yourself. Providing this information will help us learn how different types of people feel and experience life in their community. Your responses will be kept strictly confidential

Question Title

* 7. What town do you live in?

City/Town:

Question Title

* 8. How long have you lived in this town?

Years/Months

Question Title

* 9. Gender:

Male

Female

Question Title

* 10. Race/Ethnic Group:

African American/Black

American Indian/Alaskan Native

Asian

Native Hawaiian/Pacific Islander

White/Caucasian

Hispanic/Latino

Other (please specify)

Question Title

* 11. Age:

Question Title

* 12. Marital Status:

Married

Divorced

Widowed

Separated

Never Married

A member of an unmarried couple

Question Title

* 13. Education (what is the highest grade you completed?):

Never attended school

Elementary

Some High School

High School Graduate/GED

Some College or Technical School

College Degree or Higher

Other (please specify)

Question Title

* 14. Household Income:

Less than $10,000

$10,000 - $14,999

$15,000 - $19,999

$20,000 - $24,999

$25,000 - $34,999

$35,000 - $49,999

$50,000 - $75,000

More than $75,000

Question Title

* 15. How many people does this income support?

Total number of people

Number of children under 19

Number of adults

Question Title

* 16. Do you have health insurance?

Yes

Question Title

* 17. Primary language spoken in my home:

English

Spanish

Asian (Chinese, Vietnamese, Korean, Etc.Indian (Hindi, Gujarati, Punjabi, etc.)

Eastern European (Russian, Polish, etc.)

French

Other (please specify)

Burlington County Community Health & Quality of Life Survey

Question Title

* 1. Please choose the things that would "most improve" the quality of life in your community.
Select All That Apply

Question Title

* 2. From your selections above, please rank the top 3 things that would improve quality of life:

Question Title

* 3. Please choose the major “health problems” that have the "greatest impact" on overall health in your community.
Select All That Apply

Question Title

* 4. From your selections above, please rank the top 3 things that you would consider as major “health problems”:

Question Title

* 5. Please choose the major “risky behaviors” that have the "greatest impact" on overall health in your community.
Select All That Apply

Question Title

* 6. From your selections above, please rank the top 3 things that you would consider as major "risky behaviors":

Question Title

* 7. What town do you live in?

Question Title

* 8. How long have you lived in this town?

Question Title

* 9. Gender:

Question Title

* 10. Race/Ethnic Group:

Question Title

* 11. Age:

Question Title

* 12. Marital Status:

Question Title

* 13. Education (what is the highest grade you completed?):

Question Title

* 14. Household Income:

Question Title

* 15. How many people does this income support?

Question Title

* 16. Do you have health insurance?

Question Title

* 17. Primary language spoken in my home:

Question Title

* 18. How do you get information about your community?

Question Title

* 19. Additional Comments:

Question Title

* 1. Please choose the things that would "most improve" the quality of life in your community. Select All That Apply

Question Title

* 2. From your selections above, please rank the top 3 things that would improve quality of life:

Question Title

* 3. Please choose the major “health problems” that have the "greatest impact" on overall health in your community.Select All That Apply

Question Title

* 4. From your selections above, please rank the top 3 things that you would consider as major “health problems”:

Question Title

* 5. Please choose the major “risky behaviors” that have the "greatest impact" on overall health in your community.Select All That Apply

Question Title

* 6. From your selections above, please rank the top 3 things that you would consider as major "risky behaviors":

Question Title

* 7. What town do you live in?

Question Title

* 8. How long have you lived in this town?

Question Title

* 9. Gender:

Question Title

* 10. Race/Ethnic Group:

Question Title

* 11. Age:

Question Title

* 12. Marital Status:

Question Title

* 13. Education (what is the highest grade you completed?):

Question Title

* 14. Household Income:

Question Title

* 15. How many people does this income support?

Question Title

* 16. Do you have health insurance?

Question Title

* 17. Primary language spoken in my home:

Question Title

* 18. How do you get information about your community?

Question Title

* 19. Additional Comments:

* 1. Please choose the things that would "most improve" the quality of life in your community.
Select All That Apply

* 3. Please choose the major “health problems” that have the "greatest impact" on overall health in your community.
Select All That Apply

* 5. Please choose the major “risky behaviors” that have the "greatest impact" on overall health in your community.
Select All That Apply