Your participation in this Black Women's Health Survey is greatly appreciated!  The insights you provide will help the Center for Closing the Health Gap to develop a Black Women's Health Initiative that will serve black women in the Greater Cincinnati area. 

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* 1. Which three health issues concern you the most?  Please select three

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* 2. Which one health issue is most concerning to you?  Please select only one

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* 3. Why does this health issue concern you the most?

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* 4. Which three lifestyle/environmental issues concern you the most?  Please select three

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* 5. Which of following have you experienced in the past 12 months?

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* 6. Please rate your satisfaction of each factor below.

  Extremely Satisfied Somewhat Satisfied Neither Satisfied nor Satisfied Somewhat Dissatisfied Extremely Disagree
My physical health
My mental health
My spiritual health/well-being
My amount of exercise/physical activity
My eating habits/foods you eat
My home environment
My finances
My social life
My safety
Physical health of your children
Mental health of your children
Safety of my children

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* 7. For each of the statements below, please indicate how much you agree or disagree.

  Strongly agree Somewhat agree Neither agree nor disagree Somewhat disagree Strongly disagree
I think fresh vegetables are affordable in general
I think fresh fruits are affordable in general
I don’t like eating vegetables
I don’t like eating fruit
I don’t have time to cook healthy meals
I typically keep fresh fruit at home
I typically eat one fruit a day
I typically keep fresh vegetables at home
I typically eat one vegetable a day
Members in my household won’t eat vegetables
Members in my household won’t eat fresh fruit

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* 8. We find in research that words like racism mean different things to different people.  How you define racism?

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* 9. What area of your life has been impacted the most by racism in the past 12 months?

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* 10. For each of the statements below, please indicate how much you agree or disagree.

  Strongly agree Somewhat agree Neither agree nor disagree Somewhat disagree Strongly disagree
I am constantly educating white/Caucasian people about the black experience
I think about my racial identity everyday
I usually know when I am being discriminated against
I have close relationships with people outside of my race
It is possible for me to have a close relationship with someone outside of my race
I have to work harder than a white counterpart
I have access to quality healthcare
My children have access to quality healthcare
I feel listened to when I visit doctors
I prefer to have medical professionals of my own race
Only people with severe mental illness should see mental health counselors

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* 11. What is your total annual household income?

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* 12. What is the last level of education that you completed?

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* 13. What is your age range?

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* 14. Please indicate your marital status or current living arrangement. Please choose only one.

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* 15. What are the ages of all children in your household? Please check all that apply.

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* 16. Please Type Out Your Full Initials. (First Middle Last)

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* 17. Please List your Contact Information below to be eligible for the raffle.

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* 18. We are inviting select survey participants to join us for a 10-15-minute 1-on-1 conversation. If you would like to participate please check the box below.

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