Thank you for answering these anonymous questions as accurately and completely as possible!
This information will be used by several local agencies to plan service development and delivery to
communities throughout Inyo County, so the information you share will help many!

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* 1. Community you live closest to:

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* 2. Yearly Income:

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* 3. Number of people currently residing in your home:

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* 4. Your Age Range:

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* 5. Gender:

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* 6. Your Race/Ethnicity:

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* 7. Health Insurance:

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* 8. Health factors in the last 30 days (check all that apply):

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* 9. Access to Care (check all that apply):

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* 10. Someone in my immediate household has been diagnosed with the following medical condition(s):

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* 11. Someone in my immediate household has been diagnosed with the following behavioral health condition(s):

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* 12. Some regular habits that I've practiced in the past 30 days to contribute to my health include:

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* 13. Some regular habits that I've practiced in the last 30 days that are harmful to my health include:

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* 14. Some positive factors that enhance my Inyo community are :

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* 15. Some negative, or missing, factors that I'd like to see improved for my Inyo community are:

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* 16. Food Stability

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* 17. Housing

Adverse Childhood Experiences (ACEs) I experienced between birth and age 18:

Please check allĀ situations that you faced while growing up. These adversities are linked
to ongoing adult health conditions, so anonymously sharing information about your experiences
as a child helps Inyo health agencies plan relevant services and education for your community.

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* 18. Choose from the following factors

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* 19. Any community strengths, needs, or improvement ideas you would like to add that you weren't asked about?

THANKS FOR HELPING INFORM OUR EFFORTS FOR COMMUNITY HEALTH!
Inyo County Health & Human Services
Toiyabe Indian Health Project
Northern Inyo Healthcare District
Owens Valley Career Development Center
Southern Inyo Healthcare District
Inyo Mono Advocates for Community Action
Wild Iris

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