Community Needs Assessment Survey Question Title * 1. Age: Question Title * 2. Primary Language Spoken: Question Title * 3. Sex Assigned at Birth Male Female Question Title * 4. What is your gender identity? Cisgender (identify as the gender matching the sex assigned at birth. Example: Identify as woman assigned female at birth) Transgender (gender identity that does not match the sex assigned at birth.) Non-binary Genderqueer/genderfluid Question Title * 5. What ethnicity do you identify with? Non-Hispanic white Hispanic/Latino Question Title * 6. Do you currently have health insurance? If yes, please list: Question Title * 7. What is your current zip code within Deschutes County? Question Title * 8. In the past 12 months have you wanted or needed reproductive health care (e.g. Family planning visit, Pap smear, chest exam, menopause questions, etc.) Yes No Unsure Question Title * 9. In the past 12 months have you sought care for reproductive health? (e.g. Family planning, Pap smear, Chest exam, menopause questions, etc.) Yes No Unsure Question Title * 10. In the past 12 months, did cost of service prevent you from scheduling an appointment for reproductive health? Yes No Unsure Question Title * 11. In the past 12 months, did lack of transportation prevent you from scheduling an appointment for reproductive health? Yes No Unsure Question Title * 12. Is there a place within 15 minutes of where you live that you can get reproductive health services? Yes No Unsure Question Title * 13. At your last reproductive health visit, did you have to wait more than 1 hour to receive services? Yes No Unsure Question Title * 14. At your last reproductive health visit, did staff and providers speak your preferred language? Yes No Unsure Question Title * 15. At your last reproductive health visit, did you worry about your information being kept confidential by staff and providers? Yes No Unsure Question Title * 16. At your last reproductive health visit, did your appointment get rescheduled, cancelled, or moved in any way? Yes No Unsure Question Title * 17. Have you visited any of the following places in the last 12 months for reproductive health care services? Check all that apply. Mosaic Community Health Planned Parenthood Private Clinic (primary care provider office) None Other (please specify) Question Title * 18. Are you interested in receiving reproductive health care in any of the following ways? Please check all that apply. Telehealth Mobile Clinic Community-based health clinic School-based health clinic Question Title * 19. If you would like to be entered into the drawing for a $100 Visa gift card, please leave your first name and your preferred way for us to contact you in box below. Done
