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Community Survey
1. Community Survey
1
. What is your zip code?
What is your zip code?
2
. What is your age range?
What is your age range?
0-17
18-24
25-34
35-44
45-54
55-64
65-74
75-84
85-100
101 and older
3
. Gender?
Gender?
Female
Male
4
. Race/Ethnicity? (check all that apply)
Race/Ethnicity? (check all that apply)
White
African American
Asian
Native American
Hispanic
Other (please specify)
5
. What are the 3 things that would MOST improve your life? (check only 3)
What are the 3 things that would MOST improve your life? (check only 3)
Affordable housing
Health care (family doctor, dentist, etc.)
Low crime/Safe neighborhoods
More education
More jobs
More places to buy healthy foods
Nearby parks and recreation (basketball court, etc.) and/or a Community Center
Neighborhood sidewalks and/or street lights
Transportation
None of the above
Other (please specify)
6
. Which 3 things contribute the MOST to poor health in your neighborhood? (check only 3)
Which 3 things contribute the MOST to poor health in your neighborhood? (check only 3)
Alcohol and/or drug abuse
No doctors and/or dentists nearby
No place to buy fresh fruits and vegetables
No place to exercise outside/No sidewalks
Tobacco use
Too many fast food restaurants
None of the above
Other (please specify)
7
. What are the top 3 safety concerns in your neighborhood? (check only 3)
What are the top 3 safety concerns in your neighborhood? (check only 3)
Crime/Violence (gang-related activity, illegal drug activity, etc.)
Homelessness
No sidewalks and/or street lights
No safe place for kids to play
No visible law enforcement/patrols
Stray or unleashed dogs
Unsafe driving
Vacant houses/Unkempt property
None of the above
Other (please specify)
8
. What are the top 3 concerns for CHILDREN in your neighborhood? (check only 3)
What are the top 3 concerns for CHILDREN in your neighborhood? (check only 3)
Overweight or obese
No adult supervision
No place to play outside
Not enough school bus stops
Not in school during school hours
School safety
None of the above
Other (please specify)
9
. Where do you get health-related information? (check all that apply)
Where do you get health-related information? (check all that apply)
Church
Doctor's office
Family
Free health clinic
Friends/Neighbors
Health department
Internet
Library
Newspaper
Pharmacy
School
TV/Radio
Work
None of the above
Other (please specify)
10
. What prevents you and/or your family from exercising? (check all that apply)
What prevents you and/or your family from exercising? (check all that apply)
Exercise occurs in my household
Can't afford
Distance to gym/park
Mental health concerns (depression, etc.)
No childcare
Not important
No place to exercise
No time
No transportation
Physical health problems
Safety
TV/Video games
Weather (too hot/cold)
None of the above
Other (please specify)
11
. Where do you MOST often shop for food/groceries? (check all that apply)
Where do you MOST often shop for food/groceries? (check all that apply)
Angel Food/Food Share
Church/Food pantry
Convenience store/Gas station
Dollar stores
Ethnic grocery stores
Grocery store/Supermarket
Health food store
Sam's Wholesale Club
None of the above
Other (please specify)
12
. Where do you go when you and/or your family are sick? (check all that apply)
Where do you go when you and/or your family are sick? (check all that apply)
After hours clinic (Urgent care centers/Walk-in clinics)
Community health center (Mary Mahoney, Variety, etc.)
Doctor's office
Family/Home remedies
Free health clinic
Health department
Hospital clinic (OU Pediatric Clinic, etc.)
Hospital emergency department
Indian health clinic/hospital
Military health clinic
Pharmacy
VA Medical Center (Veterans Administration)
None of the above
Other (please specify)
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