Community Health Needs Assessment

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* 1. In which zip code is your home located:

54517

54821

54828

54832

54835

54838

54839

54843

54849

54859

54862

54867

54873

54875

54876

54888

54896

Other (please list zip code)

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* 2. Please choose from the list below what you believe are the top THREE community health issues:

Alcohol/Drug Use (alcoholism, impaired driving, alcohol/drug related injuries or death, access to alcohol and drug treatment programs)

Chronic Disease (diabetes, cancer, heart disease, lung disease, etc.)

Communicable Disease (COVID, Tuberculosis, tick-borne illnesses, Whooping Cough, food-borne illnesses, sexually transmitted diseases, chickenpox, measles)

Environmental & Occupational (safe supply of food and drinking water, disposal of toxic wastes, air/water/noise pollution, safe work environments)

Growth & Development (optimal opportunities for physical, behavioral, cognitive and emotional growth and change across the lifespan)

Injury & Violence (recreational injuries, car accidents, battery, assault, gang-related violence, homicide)

Mental Health (access to mental health professionals, suicide, depression, other mental disorders)

Nutrition (access to healthy foods at reasonable prices, education regarding nutrition)

Oral Health (access to dental services)

Physical Health (access to workout facilities, public recreation, walking/biking trails, weather conditions)

Reproductive & Sexual Issues (access to family planning services, birth control availability, sexually transmitted disease education)

Tobacco Use (access to tobacco, education about health implications, access to quit programs)

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* 3. What could be done to improve the health of residents in your county?

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* 4. What is preventing the residents who live in your county from achieving optimal health?

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* 5. In the past year, was there a time when you or a member of your household needed health care services, but could not get or delayed getting medical services?

Yes

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* 6. If yes, what were the three most important reasons why you did not receive health care services? (Check all that apply)

Could not schedule an appointment

Too long to wait for an appointment

Clinic was not open when I could go

Concerned about my safety during the COVID-19 pandemic

Cost is too high

Transportation problems

No insurance

Insurance won't cover it

Nervous or afraid

Not treated with respect

Clinic/Hospital cancellations due to COVID-19 Pandemic

Other (please specify)

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* 7. In your experience what is the average length of time to schedule an appointment with your primary care provider?

1-3 days

4-7 days

8-11 days

12-14 days

15+ days

Does not apply

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* 8. Please choose your age category?

Under 18

18-24

25-34

35-44

45-54

55-64

65-74

75 and over

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* 9. What gender do you identify as?

Male

Female

Other - I identify as

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* 10. With which ethnicity do you most identify?

American Indian

Asian or Asian American

Black or African American

Choose not to answer

Hispanic or Latino

White or Caucasian

Other (please specify)

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* 11. What is the highest level of education you have attained?

Less than a High School Diploma

High School Graduate or Equivalent (e.g. GED)

Associate's Degree

Bachelor's Degree

Master's Degree or Higher

Choose not to answer

Other (please specify)

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* 12. What is your employment status?

Part-time Employment

Full-time Employment

Self-Employed

Out of work and looking for work

Out of work but not currently looking for work

Homemaker

Student

Choose not to answer

Other (please specify)

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* 13. What is your total household income?

Under $15,000

Between $15,000 and $29,999

Between $30,000 and $49,999

Between $50,000 and $74,999

Between $75,000 and $99,999

Between $100,000 and $150,000

Over $150,000

Choose not to answer

Community Health Needs Assessment - 2021 Survey

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* 1. In which zip code is your home located:

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* 2. Please choose from the list below what you believe are the top THREE community health issues:

Question Title

* 3. What could be done to improve the health of residents in your county?

Question Title

* 4. What is preventing the residents who live in your county from achieving optimal health?

Question Title

* 5. In the past year, was there a time when you or a member of your household needed health care services, but could not get or delayed getting medical services?

Question Title

* 6. If yes, what were the three most important reasons why you did not receive health care services? (Check all that apply)

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* 7. In your experience what is the average length of time to schedule an appointment with your primary care provider?

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* 8. Please choose your age category?

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* 9. What gender do you identify as?

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* 10. With which ethnicity do you most identify?

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* 11. What is the highest level of education you have attained?

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* 12. What is your employment status?

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* 13. What is your total household income?

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* 14. Please share any additional comments.