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* 1. What are the top 5 healthcare needs you see in your community? (CHOOSE 5)

Please rate each of the following statements about Health Care Access in the area.

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* 2. Residents in the area are able to access a primary care provider when needed. (Family Doctor, Pediatrician, General Practitioner)

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* 3. Residents in the area are able to access a medical specialist when needed. (Cardiologist, Dermatologist, Neurologist, etc)

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* 4. Residents in the area are able to access a dentist when needed.

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* 5. There is a sufficient number of providers accepting Medicaid and Medical Assistance in the area.

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* 6. There is a sufficient number of bilingual providers in the area.

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* 7. There is a sufficient number of mental/behavioral health providers in the area.

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* 8. Transportation for medical appointments is available to area residents when needed.

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* 9. What are the most significant barriers that keep people in the community from accessing health care when they need it? (Select all that apply)

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* 10. Are there specific populations in this community that you think are not being adequately served by local health services?

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* 11. Related to health and quality of life, what resources or services do you think are missing in the community? (Select all that apply)

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* 12. What  challenges do people in the community face in trying to maintain healthy lifestyles like exercising and eating healthy and/or trying to manage chronic conditions like diabetes or heart disease. (Select all that apply)

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* 13. In your opinion, what is being done well in the community in terms of health and quality of life? (Community Assets/Strengths/Successes)

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* 14. What support groups are you aware of in the community?

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* 15. What support groups would you like to see available in the community?

Demographic Information: Please tell us about yourself.

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* 16. Do you work for the hospital, clinic, or public health unit?

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* 17. Health Insurance or health coverage status (choose ALL that apply)

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* 18. Age:

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* 19. Highest Level of Education:

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* 20. Sex:

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* 21. Employment Status:

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* 22. Your Zip Code:

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* 23. Race/Ethnicity (choose ALL that apply):

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* 24. Annual household income before taxes:

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* 25. Overall, please share concerns and suggestions to improve the delivery of local healthcare.

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