CHNA Community Survey This survey will help Baptist Health Floyd with its Community Health Needs Assessment. We want to understand the health needs in the community and how we can support you. This survey should only take five minutes. Thank you for your helpful input! Question Title * 1. Who or what do you rely on most often for health information? Please select all that apply. Public health (such as your local health department or CDC) Television (news program) Social media Healthcare provider Friend/family Radio Internet Community events AI health information (artificial intelligence such as a search engine AI summary, chatbot, health apps, etc.) Other (please specify) Question Title * 2. In your opinion, what are the most important health problems in our community? Please select the top three by using the arrows to move up selections to the top. Question Title * 3. If you are concerned about other health problems in the community not listed above, please describe them. Question Title * 4. Do you regularly visit your primary care provider for a check-up, such as an annual visit or a wellness exam? Yes No I do not have primary care. Question Title * 5. Where do you or anyone in your household go most often for routine healthcare? Select one. Physician or nurse practitioner Emergency room Health department Urgent Care Center I do not receive routine healthcare. Other (please specify) Question Title * 6. What is your gender? Female Male I prefer not to answer. Question Title * 7. In what county do you live (or where you stay most often)? Floyd Clark Harrison Washington Scott Crawford Other (please specify) Question Title * 8. What is your race/ethnicity? Select all that apply. American Indian or Alaska Native Asian Black or African American Hispanic or Latino Middle Eastern or North African Native Hawaiian or other Pacific Islander White Prefer not to answer Question Title * 9. What is the highest grade or year of school you completed? Never attended school Grades 1 through 8 Grades 9 through 11 High school graduate GED or alternative high school credential Some college credit but no degree Associates degree Bachelor’s degree Master’s degree Professional or doctoral degree Prefer not to answer Question Title * 10. What is your current employment? Homemaker Student Employed for wages Unemployed and looking for work Unemployed and NOT looking for work Retired Self-employed Unable to work Prefer not to answer Question Title * 11. What was your total household income last year? Under $10,000 $10,000 to less than $15,000 $15,000 to less than $20,000 $20,000 to less than $35,000 $35,000 to less than $50,000 $50,000 to less than $75,000 $75,000 to less than $150,000 $150,000 or more Prefer not to answer Question Title * 12. In the past year have you or any family members you live with been unable to get any of the following when it was really needed? Select all that apply. Mental health services Healthcare Childcare Elder care Food Substance use services Employment Clothing Housing Utilities Financial assistance Domestic violence assistance Transportation Adult educational services Prefer not to answer Other (please specify) Question Title * 13. What is your housing situation today? I have housing. I do not have permanent housing (staying with others, in a hotel, in a shelter, living outside on the street, in a car). I have housing today, but I am worried about losing housing in the future. Prefer not to answer Question Title * 14. Do you have any kind of health care coverage, including health insurance, prepaid plans such as HMOs, or government plans (Medicare, Medicaid, or Indian Health Service)? Yes No Not sure Prefer not to answer Question Title * 15. What barriers exist that prevent you from receiving health services? Select all that apply. No barriers exist Lack of convenient appointment times Out-of-pocket cost for appointments, procedures Lack of providers (including specialists) Unable to take time off Lack of information about where to obtain services Fear of judgement or discrimination Disability Unable to afford transportation (or afford gas) Lack of childcare Language barriers I don’t have insurance Cost of insurance deductible Other (please specify) Done
