Taylor County Community Health Assessment Survey

1. Zip Code where you live

Zip Code where you live

2. Zip Code where you work

Zip Code where you work

3. Age

Age 18-25

26-39

40-54

55-64

65 or older

4. Gender

Gender Male

Female

5. Ethnic Group

Ethnic Group African American/Black Asian/Pacific Islander Hispanic/Latino	Native American White/Caucasian
Other (please specify)

6. Language spoken at home

Language spoken at home English Spanish German	Chinese Vietnamese
Other (please specify)

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