Minnie Hamilton Health System is conducting a Community Health Needs Assessment (CHNA) Survey. By answering these questions, you will help us identify the most important health needs in your community. The information obtained from the CHNA will be used in the development of an action plan to improve the health of local community members.  Please note that you will not be asked to supply your name to complete the survey.  Respondents of the survey will remain anonymous.

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* 1. The zip code of my residence is:

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* 2. Have you or someone in your household used the services of Minnie Hamilton Health System in the past 12 months?

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* 3. If not at Minnie Hamilton Health System, at which hospital were services received?

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* 4. Why did you or someone in your household receive care at a hospital other than Minnie Hamilton Health System

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* 5. What services do you use at Minnie Hamilton Health System? (please check all that apply)

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* 6. On a scale of 1-5 (1-extremely dissatisfied, 5- extremely satisfied), how satisfied were you or someone in your household with the services you received at Minnie Hamilton Health System?

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* 7. Please explain why you were satisfied or dissatisfied.

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* 8. What type of specialist have you or someone in your household been to and in which city did you received that care?

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* 9. In what city/cities did you consult with the specialist?

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* 10. How much of a barrier are the following to receiving assistance for your needs?

  Not a barrier A small barrier A major barrier
Cost of assistance
Not eligible/do not qualify for assistance
Lack of transportation 
Lack of childcare
Do not know where to go for assistance
Do not want to ask for assistance
Assistance is not in my area
Prior bad experience with obtaining assistance
Have to work during business hours of assistance provider
Health or disability prevents me from seeking assistance

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* 11. Do you have children under age 18 living in your household?

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* 12. Do you care for an elderly parent/grandparent?

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* 13. Did you receive dental care in the past 12 months?

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* 14. If applicable, what barriers prevent you from seeing a dentist?

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* 15. Do you and/or your family have primary care physician?

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* 16. If no, then what kind of medical provider do you use for routine care?

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* 17. What is your employment status?

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* 18. Have you or someone in your household delayed health care due to lack of money and/or insurance?

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* 19. Do you or someone in your household receive treatment for any of the following conditions? (select all that apply)

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* 20. Please choose  the three most important services which should be added or expanded within Minnie Hamilton Health System.

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* 21. Please select your primary insurance carrier or provider.

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* 22. What is your age?

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* 23. What is your gender?

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* 24. What is your marital status

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* 25. What is your race

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* 26. How many people live in your household?

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* 27. What is your approximate annual household income?

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* 28. What is the highest level of education you have completed?

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* 29. Do you have any other thoughts on the healthcare provided in the community or by Minnie Hamilton Health System?

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