Southeast Iowa Regional Medical Center, Community Health Centers of Southeastern Iowa and Des Moines County Public Health are conducting a Community Health Needs Assessment survey to better understand the health concerns and needs in the community. The information gathered from this survey will be used to develop an action plan to help improve the health of our community.

All responses are anonymous.  You can skip any question you do not want to answer.  Thank you for your time!

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* 1. Part I: DEMOGRAPHICS
Age:

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* 2. Sex:

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* 3. Race/Ethnicity:

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* 4. Marital Status

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* 5. Education

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* 6. Do you have permanent housing?

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* 7. ZIP code where you live

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* 8. Household income:

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* 9. How many people currently live in your household?

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* 10. Employment

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* 11. How do you pay for your health care? (check all that apply)

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* 12. Where or how did you get this survey? (check one)

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* 13. Part II:  ACCESS AND PERSONAL HEALTH
How would you rate your health?

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* 14. Do you have one person you think of as your personal doctor or nurse?

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* 15. In the last year, how many times have you visited the following?

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* 16. What prevents you from getting medical care?

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* 17. Have you or a family member had issues accessing any of the following health services in the last year? (check all that apply)

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* 18. In the last year, have you received any of the following services or screenings? (check all that apply)

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* 19. Are you satisfied with the health care system in the community?  Consider access, cost availability, quality and options in health care.

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* 20. Have you or a family member had issues accessing any of the following resources in the last year? (check all that apply)

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* 21. Part III:  COMMUNITY HEALTH
What do you think are the five most-important factors for a healthy community? Check only five and rank them from 1-5, 1 being the highest priority:

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* 22. What do you think are the five most-important health problems in our community? Check only five and rank them from 1-5, 1 being highest priority:

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* 23. What do you think are the five most-important unhealthy behaviors/barriers in our community? Check only five and rank them from 1-5, 1 being highest priority:

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* 24. What do you think are the three things that our community does well? (Check only three)

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* 25. How would you rate the health of our community?

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* 26. List three ideas you would like to see that would improve the health of Des Moines County residents:

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* 27. Thank you for taking the time to complete this survey.  Results from Southeast Iowa Regional Medical Center, Community Health Centers of Southeastern Iowa and Des Moines County Public Health Community Health Needs Assessment and health improvement plan process will be made available to to the public when complete.

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