Skip to content
CHNA 2023
Community Health Needs Assessment 2023
All responses are CONFIDENTIAL and will be used for data purposes of the residents of Faulk County, SD and the surrounding communities.
*
1.
What is your Zip Code?
(Required.)
*
2.
Are you a smoker?
(Required.)
Yes
No
*
3.
Gender:
(Required.)
Male
Female
*
4.
Age:
(Required.)
*
5.
Marital Status:
(Required.)
Single
Married
Divorced
Widowed
*
6.
How many people live in your household (including yourself)?
(Required.)
*
7.
Race/Ethnic Origin:
(Required.)
Caucasian
Hispanic
Asian
Native American
African
Other (please specify)
*
8.
Highest level of education completed:
(Required.)
High School
Associates Degree
Bachelor's Degree
Higher education
*
9.
Are you the primary care giver for any of the following?
(Required.)
A child under the age of 18
A child with a disability over the age of 18
An older adult
No one – self only
*
10.
Do you:
(Required.)
own your home
live in another’s home/apt
live in subsidized housing
live in an assisted living facility
live in a nursing home
rent
*
11.
Do you have the following in your home?
(Required.)
Internet
cell phone
land line phone
*
12.
What are the biggest health issues or concerns in your community?
(Required.)
*
13.
Do you have health insurance?
(Required.)
Yes
No
14.
No, why?
Dropped by insurance company
lost employment
cannot pay for it
denied due to pre-existing condition
no longer qualify for Medicaid
*
15.
What do you think is the most pressing health care related need for you, your family or our community?
(Required.)
*
16.
What keeps people in our community from seeking medical attention?
(Required.)
*
17.
Where do you and your family get most of your health information?
(Required.)
*
18.
What health screenings or education services are needed in our community?
(Required.)
*
19.
In the past 12 months, have you had a(n) (check all that apply):
(Required.)
General Health exam
Mammogram
Diabetes check
Flu shot
Pneumonia shot
Skin cancer screen
Blood stool test
Dental exam/teeth cleaned
Blood pressure check
Cholesterol check
Eye exam
Hearing exam
Colonoscopy
Ultrasound
Surgery
*
20.
Have you been hospitalized in the last:
(Required.)
6 months
12 months
2 years
5 years
10+ years
Never
21.
In the past 12 months, have you or someone you know had difficulty getting needed healthcare?
Yes
No
22.
If yes, please choose reasons that apply.
Healthcare provider not available
lack of insurance
healthcare provider does not accept insurance
cannot afford co-pay
lack of transportation
language barriers
travel distance is too far
*
23.
In what ways do you think the hospital is serving the community well?
(Required.)
*
24.
In what ways could the hospital improve the way in which it serves the community?
(Required.)
*
25.
What services do you feel are needed in our community that currently do not exist?
(Required.)
*
26.
Do you see other community members working together in collaboration to address community health needs?
(Required.)
Yes
No
*
27.
Please explain:
(Required.)
*
28.
What is the number one thing the hospital could do to improve the health and quality of life of the community?
(Required.)
29.
Any other comments you think are important to address in this survey
