Community Health Needs Assessment Survey

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1. What is your zip code?
(As the goal of this survey is to indicate the health care needs of individuals living in our primary and secondary market areas we ask that only those residing in the zip codes list below respond to this survey.)

What is your zip code? (As the goal of this survey is to indicate the health care needs of individuals living in our primary and secondary market areas we ask that only those residing in the zip codes list below respond to this survey.) 15832, Driftwood

16748, Shinglehouse

15834, Emporium

16749, Smethport

15861, Sinnamahoning

16750, Turtlepoint

16720, Austin

16915, Coudersport

16724, Crosby

16921, Gaines

16726, Cyclone

16922, Galeton

16729, Duke Center

16923, Genesee

16730, East Smethport

16927, Harrison Valley

16731, Eldred

16937, Mills

16732, Gifford

16941, Genesee

16738, Lewis Run

16943, Sabinsville

16743, Port Allegany

16948, Ulysses

16744, Rew

16950, Westfield

16745, Rixford

16746, Roulette

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2. What is your age?
(Please discountinue this survey if you are under the age of 18.)

What is your age? (Please discountinue this survey if you are under the age of 18.) 18-20

21-30

31-40

41-50

51-60

61-70

71-80

80+

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3. How many individuals live in your household?

How many individuals live in your household?

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4. Number of

Number of adults in your household
children in your household

5. Do you have a primary healthcare provider?

Do you have a primary healthcare provider? Yes

No

6. If you have a primary healthcare provider, what is his/her name?

If you have a primary healthcare provider, what is his/her name?

7. Are you able to get an appointment with your primary healthcare provider when you need one?

Are you able to get an appointment with your primary healthcare provider when you need one? Yes

No

Other (please specify)

8. If you don't have a primary healthcare provider what do you do when you need medical care?

If you don't have a primary healthcare provider what do you do when you need medical care?

9. Do you think there are enough primary healthcare providers in your area?

Do you think there are enough primary healthcare providers in your area? Yes

No

10. Do you have a chronic medical condition?

Do you have a chronic medical condition? Yes

No

11. If you have a chronic medical condition, are you receiving routine medical care for the condition?

If you have a chronic medical condition, are you receiving routine medical care for the condition? Yes

No

12. Has anyone in your household seen a specialist within the past 12 months?

Has anyone in your household seen a specialist within the past 12 months? Yes

No

13. If you or someone in your household haS seen a specialist within the last year, what type of specialist and in what town/city?
(Example: Neurologist, Erie, PA)

If you or someone in your household haS seen a specialist within the last year, what type of specialist and in what town/city? (Example: Neurologist, Erie, PA) 1.
2.
3.
4.
5.
6.

14. If a specialist was seen, did the specialist(s) require additional testing such as lab work, imaging services, cardiac tests, pulmonary tests, etc?

If a specialist was seen, did the specialist(s) require additional testing such as lab work, imaging services, cardiac tests, pulmonary tests, etc? Yes

No

15. If the specialist(s) ordered additional testing, was the testing performed at Charles Cole Memorial Hospital?

If the specialist(s) ordered additional testing, was the testing performed at Charles Cole Memorial Hospital? Yes

No

16. If the specialist(s) ordered tests and they were not performed at Charles Cole Memorial Hospital, where were they performed? (Example: MRI, Geisinger Hospital)

If the specialist(s) ordered tests and they were not performed at Charles Cole Memorial Hospital, where were they performed? (Example: MRI, Geisinger Hospital) 1.
2.
3.
4.
5.
6.

17. If you had tests performed at a location other than Charles Cole Memorial Hospital, why did you have the tests performed somewhere else?

If you had tests performed at a location other than Charles Cole Memorial Hospital, why did you have the tests performed somewhere else? 1.
2.
3.
4.
5.
6.

18. In the past year were you unable to afford a prescription medication?

In the past year were you unable to afford a prescription medication? Yes

No

19. Do you and/or members of your household have any type of medical insurance?

Do you and/or members of your household have any type of medical insurance? Yes

No

20. If you and/or someone in your household does have medical insurance, how are they insured?

If you and/or someone in your household does have medical insurance, how are they insured? Through your work Through your spouse's work Through another household members' work Through COBRA Through a self-paid, private insurance plan Through CHIP	Through Medicare Through Medicaid/Medical Assistance/Access Through the Veteran's Administration Through Veteran Insurance-Champus/TriCare Through Native American/Tribal benefits
Other

21. Are you or someone in your household looking for a certain type of medical service that is not provided in your area? (Example: Endocrinology)

Are you or someone in your household looking for a certain type of medical service that is not provided in your area? (Example: Endocrinology) 1.
2.
3.
4.
5.
6.

22. Have you or someone in your household received services from Charles Cole Memorial Hospital, with the exception of emergency department visits and routine office visits, within the last year?

Have you or someone in your household received services from Charles Cole Memorial Hospital, with the exception of emergency department visits and routine office visits, within the last year? Yes

No

23. If you or someone in your household has received services from Charles Cole Memorial Hospital within the last year, what services were received (excluding emergency department and routine office visits)?

If you or someone in your household has received services from Charles Cole Memorial Hospital within the last year, what services were received (excluding emergency department and routine office visits)? 1.
2.
3.
4.
5.
6.
7.
8.
9.
10.

24. If you received services from Charles Cole Memorial Hospital within the last year, were you satisfied or dissatisfied?

If you received services from Charles Cole Memorial Hospital within the last year, were you satisfied or dissatisfied? Satisfied

Dissatisfied

25. Have you or someone in your household received services, with the exception of emergency department visits and routine office visits, within the last year some place other than Charles Cole Memorial Hospital?

Have you or someone in your household received services, with the exception of emergency department visits and routine office visits, within the last year some place other than Charles Cole Memorial Hospital? Yes

No

26. If you or someone in your household has received services within the last year from some place other than Charles Cole Memorial Hospital, where did you receive services (excluding emergency department and routine office visits)? (Example: Hamot, Erie, PA)

If you or someone in your household has received services within the last year from some place other than Charles Cole Memorial Hospital, where did you receive services (excluding emergency department and routine office visits)? (Example: Hamot, Erie, PA) 1.
2.
3.
4.
5.
6.
7.
8.
9.
10.

27. Have you or someone in your household used emergency department services within the last year?

Have you or someone in your household used emergency department services within the last year? Yes

No

28. If you received services some place other than Charles Cole Memorial Hospital, why did you choose to go some place else?

If you received services some place other than Charles Cole Memorial Hospital, why did you choose to go some place else? 1.
2.
3.
4.
5.

29. If you or someone in your household did receive emergency department services, what town/city did you receive care?

If you or someone in your household did receive emergency department services, what town/city did you receive care? 1.
2.
3.
4.
5.
6.

30. If you or someone in your household did receive emergency department care, why did you need emergency care? (Example: abdominal pain)

If you or someone in your household did receive emergency department care, why did you need emergency care? (Example: abdominal pain) 1.
2.
3.
4.
5.
6.

31. Were you satisfied or dissatisfied with the emergency department care that you received?

Were you satisfied or dissatisfied with the emergency department care that you received? Satisfied

Dissatisfied

32. Have you or someone in your household had a healthcare concern/issue for which you did not seek medical care within the last year?

Have you or someone in your household had a healthcare concern/issue for which you did not seek medical care within the last year? Yes

No

33. If you or someone in your household had a concern/issue for which you didn't seek medical care, why didn't you seek care?

If you or someone in your household had a concern/issue for which you didn't seek medical care, why didn't you seek care? 1.
2.
3.
4.
5.
6.

34. Has everyone in your household had a dental check-up within the last year?

Has everyone in your household had a dental check-up within the last year? Yes

No

35. If no, why didn't everyone in your household have a dental check-up within the last year?

If no, why didn't everyone in your household have a dental check-up within the last year? 1.
2.
3.
4.
5.
6.

36. Do you have trouble accessing healthcare due to transportation issues?

Do you have trouble accessing healthcare due to transportation issues? Yes

No

37. Do you read the nutrition labels on the food you are buying?

Do you read the nutrition labels on the food you are buying? Yes

No

38. How would you rate your overall health?

How would you rate your overall health? Excellent

Very Good

Good

Fair

Poor

1. What is your zip code?(As the goal of this survey is to indicate the health care needs of individuals living in our primary and secondary market areas we ask that only those residing in the zip codes list below respond to this survey.)

2. What is your age? (Please discountinue this survey if you are under the age of 18.)