AdventHealth Ottawa is conducting a community health needs assessment in partnership with Franklin County Health Department, Blue Cross Blue Shield of Kansas and Pathways to a Healthy Kansas. 
Your response is valuable to the continued efforts to improve our community.  Your responses will be compiled with other responses and will never directly identify your individual response. We are gathering some demographic information to ensure that we have feedback from a broad representation of individuals in the community, but this will not be shared outside the project team. You can choose to skip questions that you don’t feel comfortable answering and you can stop at any time.  Thank you for participating.

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* 1. In general, how would you rate the overall health of Franklin County?

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* 2. In general, my community has sufficient opportunities for healthy eating.

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* 3. In general, my community has sufficient opportunity for physical activity.

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* 4. If you could borrow a bike at no cost (bike share), which of the following would you use it for?  (SELECT ALL THAT APPLY)

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* 5. Approximately which of the following best describes the amount of fresh fruit and / or vegetables you eat per day?

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* 6. If you could receive 15 pounds of assorted fruits / vegetables for $15 (approximately half the normal cost) available in the town nearest you, how often would you purchase it?

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* 7. In the past 30 days, which of the following tobacco products have you used? (SELECT ALL THAT APPLY)

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* 8. Are you aware of efforts in Franklin County to promote smoking cessation (quitting smoking)?

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* 9. Please rate your level of support for policies that prohibit tobacco use in the following settings:

  Definitely not supportive Not supportive Neutral Supportive Very supportive
Local parks
School grounds
Hospital grounds
Worksite

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* 10. Are you aware of the Pathways to a Healthy Kansas initiative that is being implemented in Franklin County?

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* 11. Have you or a family member have been unable to receive mental health or substance abuse treatment?  If so, please select the reasons from the following?  (CHECK ALL THAT APPLY)

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* 12. How often in the past 12 months would you say you were worried or stressed about your finances?

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* 13. Was there a time when you needed to see a doctor but could not because of cost?

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* 14. In the past 12 months have you been worried whether food would run out before you had money to buy more?

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* 15. In the past 12 months have you experienced a time when the food you bought didn't last and you didn't have money to buy more?

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* 16. In the past 12 months has the utility company shut off your service for not paying your bills.

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* 17. Are you worried or concerned that in the next 2 months you may not have stable housing that you own, rent or stay in as part of a household?

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* 18. Are you afraid you or a family member might be hurt in your apartment building or house?

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* 19. Do problems getting childcare make it difficult for you to work or study?

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* 20. How often do you feel?

  Hardly ever Some of the time Often
That you lack companionship
Left out
Isolated

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* 21. Which age category are you in?

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* 22. How do you describe yourself?

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* 23. What is your race?  (SELECT ALL THAT APPLY)

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* 24. Are you of Hispanic, Latino or Spanish origin?

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* 25. What is the highest level of school, college or vocational training that you have finished?

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* 26. What kind of health insurance or health care do you have?

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* 27. What was your total household income last year before taxes?

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* 28. How many people are in your household?

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* 29. What is your zip code?

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