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2019 Community Health Needs Survey
1.
What county do you live in?
Caroline
Dorchester
Kent
Queen Anne's
Talbot
2.
What is your zip code?
3.
What is your sex?
Male
Female
4.
Which one of the following is your race?
Please check all that apply.
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or other Pacific Islander
White
Don't know
Prefer not to answer
Other (please specify)
5.
Are you Hispanic or Latino/a?
Yes
No
Don't know
Prefer not to answer
6.
On how many days during the past 30 days was your mental health not good?
Mental health includes stress, depression and problems with emotions. Please write number of days.
Zero days
Don't know
Prefer not to answer
Days
7.
What are the three most important health problems that affect the health of your community?
Please check only three
Alcohol/Drug addiction
Alzheimer’s/dementia
Cancer
Diabetes/high blood sugar
Heart disease/blood pressure
HIV/AIDS
Infant death
Lung disease/asthma/COPD
Mental health (depression, anxiety)
Overweight/obesity
Smoking/tobacco use
Stroke
Don’t know
Prefer not to answer
8.
What are the three most important social/environmental problems that affect the health of your community?
Please check only three
Availability/ access to doctors’ office
Availability/access to insurance
Child abuse/neglect
Domestic violence
Housing/homelessness
Lack of affordable child care
Lack of job opportunities
Limited access to healthy food
Limited places to exercise
Neighborhood safety/violence
Poverty
Race/ethnicity discrimination
School dropout/poor schools
Transportation problems
Don’t know
Prefer not to answer
9.
What are the three most important reasons why people in your community do not get health care?
Please check only three
Cost- too expensive/can’t pay
Cultural/religious beliefs
No doctor nearby
No insurance
Insurance not accepted
Lack of transportation
Language barrier
Wait is too long
Don’t know
Prefer not to answer
10.
What ideas or suggestions do you have to improve health in your community?
11.
To be entered into the $100 Amazon Gift Card Raffle, please leave your contact information below (Optional)
Name
Email Address
Phone Number
Current Progress,
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