1. Before you take this survey, please read the following:

The purpose of this survey is to find out how the Faith Community Health Ministry  can meet the health interests and needs specific to your faith community.

Your participation is voluntary. The survey should take no longer than 5-10 minutes to complete. Please answer all the questions to the best of your ability.
The information you provide is anonymous. There will not be any personal identifiers connecting you to your answers. All results will be computed as a group instead of individually. Your faith community nurse or health promoter will receive a summary of the results to plan health ministry support and programs this year.

If you have read and understand these instructions, please complete the survey below. Thank you so much for your participation.

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* 1. What is your gender?

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* 2. What is your age?

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* 3. What is your race/ethnicity?

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* 4. Are you of Latino or Hispanic descent?

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* 5. In general, how would you rate your overall health?

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* 6. Do you currently have health insurance coverage? (private insurance, Medicare, Medicaid, etc.)

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* 7. Do you have a PCP or primary care provider? (such as a doctor, nurse practitioner, physicians assistant)

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* 8. When was the last time you had a physical exam and blood work done

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* 9. How do you like to receive health information in your faith community? Select all that apply.

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* 10. If you were to attend  a health related program,  or educational session, what location would you prefer? Select all that apply

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* 11. What assistance would be helpful to encourage you to attend a program  or educational session in person? Select all that apply

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* 12. What days and times during the week would you be interested in attending a program or educational session? Select all that apply.

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* 13. Which of the following  activities/services would be a benefit to you? Select all that apply.

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* 14. Would you be interested in information about the following health topics? Select all that apply.

Our health starts in our families,  places of worship, workplaces, schools, playgrounds, parks, in the air we breathe and the water we drink. The following questions will help us to understand the various needs that could  have an impact on health. If you have a specific need please reach out to your Faith Community Nurse or Health Promoter in your faith community.

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* 15. In the past year, have you or any family members you live with been unable to get or are you in fear of losing any of the following? Select all that apply.

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* 16. Do  you have somebody that you can count on  at anytime you need help?

Thank- you for completing this survey

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* 17. What state and county do you live in?

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