2021 Survey

We are conducting a Community Health Needs Assessment survey to better understand the health concerns and needs of our communities. This survey is anonymous and your input is vital in helping us improve the health of our communities.  This survey was developed in collaboration with the Apache County Public Health Services District, Little Colorado Behavioral Health Center, North Country Healthcare, Round Valley Unified School District and White Mountain Regional Medical Center.

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* 1. Zip Code:

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* 2. Gender (at time of birth):

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* 3. Age:

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* 4. Ethnic Background:

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* 5. Marital Status:

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* 6. Housing Status:

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* 7. Employment Status:

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* 8. In which County do you reside, and how long have you lived there?

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* 9. What is your annual household income?

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* 10. Are you or anyone living in your home a veteran?

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* 11. Do you have any children living at home?

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* 12. Child 1

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* 13. Child 2

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* 14. Child 3

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* 15. Child 4

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* 16. Child 5

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* 17. Child 6

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* 18. How would you describe your overall health?

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* 19. Have you or anyone living in your home received medical services in a County other than Apache County?

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* 20. Do you or anyone living in your home have medical insurance?

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* 21. Do you or anyone living in your home have a primary care Physician/Provider?

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* 22. Is your primary care Physician/Provider in Apache County?

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* 23. Have you or anyone living in your home been treated by a Physician/Provider within the past 12 months?

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* 24. Have you or anyone living in your home been treated for, or diagnosed with, any of the following? (If no, please skip to question #28)

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* 25. For which of the health issues listed above in Question #24  did you seek treatment outside of Apache County? (Please specify)

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* 26. Are you or anyone living in your home taking prescription medications for any of the health issues listed in question #24?

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* 27. Are you or anyone living in your home taking supplements for any health issues listed in question #24?

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* 28. Do you or anyone living in your home receive mental health or substance abuse services in Apache County?

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* 29. Do you or anyone living in your home have dental insurance?

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* 30. Do you or anyone living in your home receive routine preventative dental check-ups in Apache County?

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* 31. Do you or anyone living in your home have vision insurance?

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* 32. Do you or anyone living in your home receive routine vision care services in Apache County?

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* 33. Have you or any women living in your home received women's services within the past 12 months?

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* 34. Are all the children living in your home up to date on their immunizations?

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* 35. Where do the children living in your home receive their immunizations?

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* 36. In the last month the majority of meals served in my home were:

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* 37. In the last week how many days have you or anyone living in your home gone hungry because you could not afford food?

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* 38. On average how many recreational hours per day do you or those living in your home spend on electronic devices or watching television?

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* 39. I feel like I belong in my community?

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* 40. My children feel like they belong in their school?

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* 41. My children feel safe at their school?

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* 42. I am involved in community groups?

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* 43. I am prepared in the event of an emergency or evacuation?

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* 44. I would know where to find help or assistance if.....(please choose all that apply)

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* 45. In light of the COVID-19 Pandemic, how strongly do you agree or disagree with the following statements?:

  Strongly Agree Agree Neutral Disagree Strongly Disagree
You and/or your families health needs were met within Apache County:
I feel safe in the way COVID-19 has been handled within Apache County:

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* 46. In what way has COVID-19 impacted you/your family members lives over the past year? (Please select all that apply)

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* 47. Please rate the following statements from strongly agree to strongly disagree:

  Strongly Agree Agree Neutral Disagree Strongly Disagree
I trust that my health needs will be met and properly cared for within Apache County:
I trust my privacy will be respected when I visit local offices/entities within Apache County:
I feel comfort in personally knowing the people who care for the health needs of myself and/or my family within the community:
I trust my privacy will be respected even if I personally know the person(s) I see while attending to my health needs:

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* 48. Would you and/or your family members utilize a public swimming pool for therapy and/or rehab services?

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* 49. Do you and/or family members receive dialysis services outside of our service area?

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* 50. If there are any additional concerns you have, please list them below:

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* 51. If you have questions or would like someone to contact you regarding this Survey, please list your contact information below:

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