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* 1. Where do you live? (check all that apply)

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* 2. Which best describes you?

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* 3. What best describes your age group? (check all that apply)

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* 4. What is your gender?

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* 5. Which best describes your household?

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* 6. Which best describes your employment?

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* 7. Which describes your education level? (Check all that apply)

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* 8. How would you rate your health? 

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* 9. Which insurance do you have? (Check all that apply)

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* 10. If you do not have insurance, specify why.

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* 11. Based on your experiences, what are the two greatest healthcare needs in our community?

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* 12. Do you know of any programs that have been implemented elsewhere in the state to address these needs that could be implemented in our community?  If so, please list the name of the program and the community where implemented.

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* 13. Based on your experiences, what are the major barriers to healthcare? (Check all that apply)

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* 14. What resources would help you most? (check all that apply)

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