Community Health Needs Assessment Survey

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* 1. How old are you?

Under 18

Between 18 and 25 years old

Between 26 and 39 years old

Between 40 and 54 years old

Between 55 and 64 years old

Between 65 and 74 years old

Older than 74 years old

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* 2. Identify your gender:

Male

Female

Other (please specify)

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* 3. Identify your race. (Check all that apply)

American Indian or Alaskan Native

Asian

Black/African American

Hispanic/Latinx

White

Other (please specify)

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* 4. If you have insurance, what is your status?

Medicaid

Medicare

Parent's insurance

Private insurance

Spouse's insurance

Through employer

Veteran’s Health Care Benefits

I do not have insurance.

Other (please specify)

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* 5. What county do you live in?

Ballard

Calloway

Carlisle

Fulton

Graves

Hickman

Livingston

Marshall

McCracken

Pope, IL

Massac, IL

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* 6. Identify your primary transportation:

Friend/Family member

Personal vehicle

Walk

Bicycle

Public (Example: Bus)

Cab/Lyft/Similar

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* 7. What risk factors affect your personal health? (Check all that apply)

Alcohol use

Tobacco/Nicotine use (Example: Cigarettes/Vaping)

Illicit substance use (Example: Opioids/Marijuana/Meth)

Physical inactivity

Unhealthy diet

Food Insecurity/Hunger

Abandoned/Neglected as a child

Isolation/Loneliness

Physical abuse

Crime

Homelessness (Example: Couch surfing)

Incarceration

Low income

Mental health

Unemployment

Other (please specify)

None of the above

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* 8. Identify the health challenges you face. (Check all that apply)

Alcohol use disorder

Arthritis

Asthma

Cancer

Diabetes

Heart disease

High blood pressure

Joint/Back pain

Lung disease

Mental health

Nicotine/Tobacco use

Overweight/Obesity

Substance use disorder

I don’t have any health challenges.

Other (please specify)

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* 9. Are there barriers that prevent you from accessing health care? (Check all that apply)

Cultural/Religious beliefs

Fear of being judged

Lack of providers

Lack of appointments

Language barriers

No insurance

Quality of providers

Transportation

Unable to pay co-pays/Deductibles

I do not have barriers.

I do not know how to access.

Other (please specify)

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* 10. What factors influence your health choices? (Check all that apply)

Family

Friends

Significant other

Other people around you

Community

How you feel in the moment

Listening to physicians, healthcare professionals

Public health recommendations/guidelines (Example: CDC)

Social media

Access to parks/walking trail

Weather (Seasons: Spring, Summer, Fall, Winter)

Other (please specify)

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* 11. Where do you get most of your healthcare information? (Check all that apply)

Doctor/Healthcare provider

Flyers/Posters

Friends/Family

Google, Yahoo, and other search engines

Health Department

Library resources

Local hospital website

News Paper/Magazines

Radio/Television

Social Media

I don’t access health care information

Other (please specify)

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* 12. Do you and your family get any of the following regular health screenings or vaccines? (Check all that apply)

Annual physical

Blood pressure

Colonoscopy

Mammogram

Other cancer screenings

COVID-19 Vaccine

Dental check ups

Diabetes Screenings

Flu Vaccine

Vision Screenings

I don’t get regular screenings/vaccinations.

Other (please specify)

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* 13. What is your barrier to the recommended weekly physical activity (30 minutes of moderate (walking at a fast pace) exercise, 5 times a week)? (Check all that apply).

Child Care

Cost

Lack of bike lane/shoulder/trail

Lack of facility (Example: gym/public pools/group classes)

Lack of knowledge

Motivation

No parks/Side walks

No transportation

Safety (Example: street lights/hit by a car/crime)

Side walks (Example: no side walks/damaged)

Time

I don’t have a barrier; I exercise the recommended amount.

Other (please specify)

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This graphic will assist you in answering the next question.

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* 14. According to the American Heart Association, a person should consume 4 servings of fruit and 5 servings of vegetables per day. What are your barriers to the recommended daily consumption of fruits and vegetables? (Check all that apply).

Access

Cost

Knowledge

Options

Preference

I don’t like the taste of fruits and vegetables

None

Other (please specify)

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* 15. What type of treatment and/or supports have you utilized for substance use disorders/mental health in the past 12 months? (Check all that apply).

AA/NA

Counselor/Therapist

Emergency Room (ER)

Medically assisted treatment

Peer led

Primary care physician

Programs

Psychiatrist

Faith based leader (priest/pastor)

Religious associations

Support groups

I could benefit from these services but haven't

I haven’t needed to use these services.

Other (please specify)

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* 16. Is your community a good place to...

	Yes	No
Raise Children?	Raise Children? Yes	Raise Children? No
Retire?	Retire? Yes	Retire? No
Live?	Live? Yes	Live? No

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* 17. Are you currently...

Living with family (parent(s), guardian, grandparents, or other relatives)

Couch surfing or moving from home to home

Group homes

Living on your own (apartment, house, etc.)

Living in a place not meant to be a residence, such as outside, in a tent city or homeless camp, in a car, in an abandoned vehicle or in an abandoned building

Recovery housing

Residential treatment

Staying in an emergency shelter or transitional living program

Staying in a hotel or motel

Community Health Needs Assessment Survey

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* 1. How old are you?

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* 2. Identify your gender:

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* 3. Identify your race. (Check all that apply)

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* 4. If you have insurance, what is your status?

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* 5. What county do you live in?

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* 6. Identify your primary transportation:

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* 7. What risk factors affect your personal health? (Check all that apply)

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* 8. Identify the health challenges you face. (Check all that apply)

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* 9. Are there barriers that prevent you from accessing health care? (Check all that apply)

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* 10. What factors influence your health choices? (Check all that apply)

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* 11. Where do you get most of your healthcare information? (Check all that apply)

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* 12. Do you and your family get any of the following regular health screenings or vaccines? (Check all that apply)

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* 13. What is your barrier to the recommended weekly physical activity (30 minutes of moderate (walking at a fast pace) exercise, 5 times a week)? (Check all that apply).

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This graphic will assist you in answering the next question.

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* 14. According to the American Heart Association, a person should consume 4 servings of fruit and 5 servings of vegetables per day. What are your barriers to the recommended daily consumption of fruits and vegetables? (Check all that apply).

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* 15. What type of treatment and/or supports have you utilized for substance use disorders/mental health in the past 12 months? (Check all that apply).

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* 16. Is your community a good place to...

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* 17. Are you currently...

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* 18. What major issues does the community need to address? (Check all that apply).

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* 19. How has the COVID pandemic impacted your life? (Check all that apply).