1. Community Voice Survey

Thank you for giving Raphael Health Center your time and consideration. Raphael wants to hear from you about the priorities for the community it serves. Please take a few minutes to respond to the questions in the survey. All responses are confidential and are not tracked to the contributor. The results of Raphael's Community Voice Survey will be posted on the Raphael website: www.Raphaelhc.org. This information will help Raphael to strategically plan for the future. Again, Thank you for your time.

* 1. Do you live in one of the following Zip Codes?

* 2. What do you believe are the top three health concerns for the community Raphael serves?

* 3. Please note any health concerns you do not see listed, but believe should be included:

* 4. Please rank the top three social issues in the community Raphael serves:

* 5. Please include any social issue not listed in question 4 but you believe should be addressed:

* 6. Think about the availability of health services in the community and choose the top three areas that need to have better availability within the community:

* 7. Please list any health care service that you believe needs to be made available in the community, and is NOT listed above:

* 8. What is your # 1 concern in accessing healthcare:

* 9. Please rank (by order of preference) the way you like to receive health information:

* 10. Was there any time in the past 12 months where you put off getting medical care that you thought you needed?

* 11. Please comment on the main reason you delayed getting healthcare in the last 12 months:

* 12. Have you ever heard your primary care office referred to as a "Medical Home"?

* 13. Which of the following answers best describes a "Primary Care Home"

* 14. In the past 12 months have you, or has anyone in your household, visited the Emergency Room?

* 15. If you visited the Emergency Room in the last 12 months, please click on the reason listed below:

* 16. What is your age?

* 17. What is your ethnicity? (Please select all that apply.)

* 18. What is your gender?

* 19. What changes would most improve this neighborhood?

* 20. What types of activities would you participate in if they were available in this neighborhood?

* 21. In what language do you read most often?

* 22. What is the highest level of school you have completed or the highest degree you have received?

* 23. Overall, how safe do you feel in this neighborhood?

* 24. Thinking over the next two to three years, which, if any changes by Raphael Health Center would you prioritize?

* 25. Please rate how well you believe The Mission of Raphael Health "to provide community based, full-service health care of the highest quality, with respect and dignity for all people, including the underserved and uninsured, within a setting that share the lover and healing of Jesus Christ", is being fulfilled currently.

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