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Clay County IPLAN Community Health Assessment
1.
Household Zip Code
2.
Work Zip Code
3.
What is your age?
4.
What is your sex designated at birth?
Male
Female
Prefer not to answer
5.
What is your ethnicity?
American Indian or Alaska Native
Asian or Asian American
Black or African American
Hispanic or Latino
Middle Eastern or North African
Native Hawaiian or other Pacific Islander
White
Another race
Prefer not to answer
6.
What type of structure is your home?
Single Family
Mobile Home
Multiple Unit
Other (please specify)
7.
How many people currently live in your household?
8.
How many people in your household are:
Less than 2 years old?
2-17?
18-65?
More than 65?
Don't know
9.
Is there an adult in your household who struggles to understand English?
Yes
No
Don't know
10.
In relation to question 9, if so, what is their preferred language?
11.
Does your household have a working smoke alarm?
Yes
No
Don't know
12.
Does your household have a working carbon monoxide detector?
Yes
No
Don't know
13.
Have you or a member of your household even been told by a healthcare professional that he/she has: (check all that apply)
Asthma/COPD/Emphysema
Pre-Diabetes
Diabetes
Developmental Disability
Hypertension/Heart Disease
Immunosuppressed
Physical Disability
Mental Illness
None of the above
Don't know
14.
Do you receive any of the following in Clay County? Check all that apply.
Medical
Dental
Mental Health
None of the above
15.
Do you or a member of your household use: (Check all that apply)
Daily Medication (other than birth control or vitamins)
Dialysis
Home Health Care
Oxygen Supply
Wheelchair/Cane/Walker
Transportation Services
Other type of special care
None of the above
16.
Does your household currently have the following: (Check all that apply)
Adequate drinking water (besides tap) for the next 3 days (1 gallon/person/day)
Adequate non-perishable food for the next 3 days
Adequate food and water for your pets for the next 3 days
A 7-day supply of medication for each person who takes prescription medication
A first aid kit that you could take with you if you had to leave quickly
None of the above
17.
If an emergency happened in our community, what would be the main source of information for your household to keep up-to-date on the event? Check up to 3 options.
TV
Radio
Text Message
Automated call
Local Newspaper
Word of mouth (family, friend, neighbor)
Poster/Flyer
Church
Social Media
Other internet site
Don't know
Other (please specify)
18.
If your household had to evacuate due to a large scale disaster or emergency, where would you go? You may only select one.
Friends/Family/2nd home outside of area
Hotel/Motel
American Red Cross, church, or community shelter
Would not evacuate
Don't know
Other (please specify)
19.
What would be the main reason that might prevent you from evacuating? You may only select one.
Lack of Transportation
Lack of trust in public officials
Concern about leaving property
Nowhere to go
Concern about personal safety
Concern about pets/livestock
Concerns about traffic
Inconvenient/expensive
Health Problems
Don't know
Other (please specify)
20.
Does your home have any of the following occurring? Select all that apply.
Structural Hazards
Fear of future disaster
Fear of Crime
Pestilence (bugs, mice, termites, etc.)
Air Quality Concerns (smoking, mold, mildew)
Other (please specify)
21.
Has your household ever been tested for Radon?
Yes
No
Don't know
22.
Do you use any of the following to protect yourself from mosquitoes? Check all that apply.
Wear repellent
Eliminate standing water
Wear protective clothing
None
Other (please specify)
23.
What sun cancer prevention do you use? Select all that apply.
Hat/Shades
Sunscreen
Protective Clothing
None
Other (please specify)
24.
How many days during the last 7 days did you or a member of your household eat a meal from a restaurant or other food vendor?
25.
Is there anything that prevents your household from eating nutritious food? Select all that apply.
Local Availability
Expensive
Local Selection quality
Time for preparing
Other
N/A Nothing Prevents
I don't want to.
Don't know.
26.
How many days in the last 7 days did you or a member of your household perform at least 30 minutes of physical activity (other than doing your regular job)?
27.
Is there anything that prevents your household from exercising? Check all that apply.
Expensive
Distance
Don't have time
Limited gym options
Physical Disability
Other health concern
Don't want to
N/A nothing prevents
Don't know
Other (please specify)
28.
Who does your household use for primary or ongoing medical care? Choose one.
Hospital ER
Doctor's clinic
Urgent Care/Walk-in Clinic
Military
Don't know
Other (please specify)
29.
What prevents your household from seeking medical attention? Choose all that apply.
Unable to get an appointment
Inconvenient provider office hours
Distance
Lack of Transportation
Cost/Lack of or insufficient coverage
N/A Nothing Prevents
Don't know
Other (please specify)
30.
Has a healthcare provider ever discussed cancer risk or early detection cancer screenings with you or a member of your household?
Yes
No
Don't know
31.
In the past 12 months, how many members of your household have tried to quit smoking cigarettes or using a tobacco product?
32.
When did you last see a dental provider?
Within the past 6 months
Within the last year
Over 2 years ago
Don't know
33.
What is your pay source for healthcare? Choose all that apply.
Medicare
Medicaid
Private Insurance
Self-pay
Don't know
34.
How would you rate Clay County as a "healthy community"? Would you say Clay County is...
Very healthy
Healthy
Somewhat healthy
Unhealthy
Very unhealthy
Don't know
35.
What do you think are the 3 most important health problems in Clay County?
1.
2.
3.