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Community Needs Assessment Survey
1.
Age:
2.
Primary Language Spoken:
3.
Sex Assigned at Birth
Male
Female
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
5.
What ethnicity do you identify with?
Non-Hispanic white
Hispanic/Latino
6.
Do you currently have health insurance? If yes, please list:
7.
What is your current zip code within Deschutes County?
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
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
10.
In the past 12 months, did cost of service prevent you from scheduling an appointment for reproductive health?
Yes
No
Unsure
11.
In the past 12 months, did lack of transportation prevent you from scheduling an appointment for reproductive health?
Yes
No
Unsure
12.
Is there a place within 15 minutes of where you live that you can get reproductive health services?
Yes
No
Unsure
13.
At your last reproductive health visit, did you have to wait more than 1 hour to receive services?
Yes
No
Unsure
14.
At your last reproductive health visit, did staff and providers speak your preferred language?
Yes
No
Unsure
15.
At your last reproductive health visit, did you worry about your information being kept confidential by staff and providers?
Yes
No
Unsure
16.
At your last reproductive health visit, did your appointment get rescheduled, cancelled, or moved in any way?
Yes
No
Unsure
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)
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
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.
