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* 1. How would you rate the community where you live? Please select one

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* 2. Please choose the FIVE most important health problems you believe are in Randolph County.

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* 3. Please choose the top FIVE  unhealthy behaviors you believe are in Randolph County.  

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* 4. Please choose the top FIVE community issues that you believe have the greatest effect on quality of life for Randolph County residents.

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* 5. In general, would you say your health is...?

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* 6. Do you use tobacco products? This includes cigarettes, dip, e-cigarettes, Juul, etc.

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* 7. If yes, what tobacco products do you use? Check all that apply. 

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* 8. If you use tobacco products and wanted to quit, what resource would you most likely use? 

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* 9. Are you exposed to secondhand smoke in any of the following places? (Check all that apply)

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* 10. In the past 30 days, have you used a prescription drug that was not prescribed to you?

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* 11. In the past 30 days, have you used a drug that was classified as illegal?

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* 12. If yes to number 10 or 11, which of the following substances have you used in the past 30 days? 

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* 13. How many days a week do you get at least 30 minutes of physical activity?

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* 14. If you are physically active, what types of activity do you do most often?

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* 15. If you are not physically active, why aren't you? Check all that apply. 

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* 16. How many servings of fruit and vegetables do you eat daily? (Serving=1 cup raw or leafy greens, 1/2 cup cooked; 1 medium sized apple, orange, banana)

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* 17. If you do not eat fruits and vegetables, why don't you? Check all that apply.

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* 18. How many times a week do you eat out (fast food, chain restaurants, fine dining etc.)?

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* 19. How many miles is the closest grocery store from your home?

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* 20. How many days a week does your child/children get at least 120 minutes of any physical activity? This includes activity from recess/gym at school

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* 21. If your child is physically active, what activity do they do most often? If you do not have children, please write "I do not have children."

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* 22. How many servings of fruits and vegetables does your child/children eat daily? (Serving =1/2 cup of fruit or vegetable; 1/2 cup of vegetable or tomato juice)

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* 23. How many times a week does your child/children eat out (fast food, chain restaurants, fine dining, etc.)?

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* 24. Is your child/children, age 0-5, in child care or preschool?

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* 25. If yes, which best describes the center or preschool?

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* 26. If no, why?

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* 27. If you work AND your child is not in a childcare center, home, or preschool, which best describes your childcare arrangements?

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* 28. Are you covered by a health insurance plan?

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* 29. If yes, what type (Check all that apply.) 

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* 30. Where do you go for routine healthcare when you are sick? (Please choose one)

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* 31. In the last 12 months, did you receive dental care? This includes check ups, cleanings, or any other reason for seeing a dentist.

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* 32. If no, why could you not get dental care?

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* 33. How often do you take your child/children for routine dental care?

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* 34. Where do you get most of your health related information? Select all that apply. 

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* 35. In the last 12 months, have you or your family needed a health related service (ex. specialist, primary care, dentist, etc) that you could not find in the community

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* 36. If yes, which service were you not able to find?

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* 37. Does your home have working smoke detectors?

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* 38. Does your home have working monoxide detectors?

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* 39. Does your family have a basic emergency supply kit? (To include water, non-perishable food, any necessary prescriptions, first aid supplies, flashlight, batteries, blanket, etc)

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* 40. If yes, how many days do you have supplies for?

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* 41. What would be your main way of getting information from the authorities in a large scale disaster emergency? (Please choose one)

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* 42. How old are you?

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* 43. Are you Male or Female?

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* 44. What is your race?

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* 45. Do you speak a language other than English in your home?

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* 46. What is your marital status?

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* 47. What is the highest level of school, college, or degree that you have finished?

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* 48. What is your annual household income?

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* 49. What is your employment status?

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* 50. What is your zip code?

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