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* 1. What is your zip code?

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* 2. What is your age:

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* 3. What is your sex?

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* 4. What is your race or origin?

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* 5. How do the following issues impact the health of your county:

  Very Negative Impact Some Negative Impact No Impact Some Positive Impact Very Positive Impact
Homelessness
Resources for homeless people
Availability of housing
Cost of housing
Adult obesity
Childhood obesity
Access to nutrition education (like healthy recipes or cooking classes)
Access to healthy food
Cost of healthy food
Diabetes
Heart Disease
Access to pediatric and child health care
Child abuse and neglect
Tobacco use
Electronic cigarette, "vaping," e-cigarette use
Alcohol use
Opioid use
Methamphetamine use
Other illegal drug use
Depression
Stress/Anxiety
Access to mental or behavioral health care
Cost of mental or behavioral health care
Availability of high-speed Internet
Cost of high-speed Internet

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* 6. Do you see a need for the following in your county:

  No need Some need No opinion either way Definite need Extreme need
Resources for homeless people
Housing
Low-income housing
Nutrition education (like healthy recipes or cooking classes)
Places to buy healthy foods
Affordable healthy foods
Exercise facilities/classes
Chronic disease education
Parenting classes
Tobacco prevention education
Tobacco cessation education/resources
Substance use prevention education
Substance use education/resources
Recovery and rehabilitation programs for individuals with Substance Use Disorder
Mental or behavioral health providers
Telehealth services for mental or behavioral health
Pediatric and child health care
High-speed Internet
Cost of high-speed Internet
Educational resources for young adults after high school
Life skills for young adults after high school
Resources for abused or neglected children
Increased awareness of available services/organizations that already exist in the county
Increased awareness of medical services that already exist in the county

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* 7. Open comments:

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