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Community Engagement
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1.
What county do you live in?
(Required.)
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2.
My zip code is:
(Required.)
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3.
I have this type of health care coverage:
(Required.)
Private/Employer-Sponsored Insurance
Affordable Care/Obamacare/Marketplace
Medicaid
Medicare
No Insurance
Other (please specify)
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4.
A doctor, nurse, or other healthcare provider, told me that I have the following: (Check all that apply)
(Required.)
High blood pressure
High blood sugar (diabetes)
High cholesterol
None of the above
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5.
My main form of transportation is:
(Required.)
Bicycle
Bus
Car
Taxi
Walk
Other (please specify)
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6.
I think these are 3 main reasons why people in our community do not seek health care:
(Required.)
Cannot get time off
Does not know where to go
Hours not convenient
No one to keep children
Not sick
No family doctor
No insurance
No way to get there
Fear
Other (please specify)
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7.
I think these are 3 main reasons that prevent people from being physically active in our community:
(Required.)
Crime
Heat/Cold
No community events
No street lights
No parks/outdoor spaces
Traffic
Not enough bike lanes
Not enough sidewalks
Personal choice
Stray dogs/animals
Too tired after work
Other (please specify)
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8.
I think these are 3 main reasons that prevent people in our community from eating healthy foods:
(Required.)
Don’t cook at home
Eats fast food regularly
No community gardens
No farmers markets
No grocery store near by
Too expensive
Stores don’t accept SNAP/EBT/WIC
Stores don’t have quality produce
May not know how to eat healthy
Too tired after work
Other (please specify)
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9.
I think these are the 3 most important health concerns in our community:
(Required.)
Alcohol use
Alzheimer’s/Dementia
Arthritis
Cancer
Diabetes
Drug Use
Heart disease/Stroke
High blood pressure
HIV/AIDS/STDs
Infant death
Mental health
Overweight/Obesity
Tobacco use
Other (please specify)
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10.
I think these are the 3 most important factors for a healthy community:
(Required.)
Acceptance of all people
Access to affordable healthcare
Access to affordable and healthy foods
Access to safe places to be active
Clean environment
Good jobs/healthy economy
Good schools
Low crime
Low disease rates
Neighbors helping neighbors
Smoke free work place
Strong faith and fellowship
Other (please specify)
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11.
I would rate the overall health of our community as:
(Required.)
Poor
Fair
Good
Very good
Excellent
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12.
I use the following tobacco products. (Check all that apply)
(Required.)
I don’t use tobacco products
Chew tobacco, dip, snuff, snus
Cigarettes
Cigars or little cigars
Pipes
Alternative tobacco products (e-cigs, or electronic cigarettes)
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13.
I agree with the idea of smoke free workplaces, including restaurants and bars.
(Required.)
Yes
No
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14.
I am exposed to secondhand smoke (i.e. smoke from someone else who may be smoking in my home, workplace, or public place).
(Required.)
Yes
No
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15.
If you are exposed to secondhand smoke, where? (Check all that apply):
(Required.)
Vehicle
Home
Work
I am not expose to secondhand smoke
Other (please specify)
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16.
In the last 2 days, how many fruits and vegetables have you eaten?
(Required.)
None
1-2
3-4
5 or more
Other (please specify)
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17.
In the last week, how many times were you physically active or exercised?
(Required.)
None
1-2
3-4
5 or more
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18.
How important is it to be physically active or exercise?
(Required.)
Not important
Important
Extremely important
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19.
How important is it to eat fruits and vegetables?
(Required.)
Not important
Important
Extremely important
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20.
In the last 30 days when I bought fruits and vegetables, they were? (Check all that apply)
(Required.)
Fresh
Frozen
Canned
Can't afford to buy
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21.
What age range are you?
(Required.)
18-25
26-39
40-54
55-64
65 or older
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22.
Are you male or female?
(Required.)
Male
Female
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23.
Which race/ethnic group do you most identify with? (Choose only one)
(Required.)
White
Black or African American
American Indian or Alaska Native
Native Hawaiian or Pacific Islander
Asian
More than one race
Some other race
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24.
Are you of Hispanic, Latino or Spanish origin?
(Required.)
Yes
No
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25.
What is your current employment status? (Choose all that apply)
(Required.)
Employed for wages
Self-employed
Out of work and not currently looking for work
Out of work and looking for work
A homemaker
Student
Military
Retired
Unable to work
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26.
What was your total family income last year before taxes? (Choose only one)
(Required.)
Less than $25,000
$25,000 - $39,999
$40,000 - $59,999
$60,000 - $79,999
$80,000 - $99,999
$100,000 or more
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27.
What is the highest level of school, college, or vocational training you finished? (Choose only one)
(Required.)
Did not finish high school
High school graduate (or GED)
Technical college
Bachelor’s degree
Graduate Degree
Doctorate or higher
Other (please specify)
Current Progress,
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