Dickinson County Community Perception Survey

Your community is part of Pathways to a Healthy Kansas, a Blue Cross and Blue Shield of Kansas initiative.  The purpose of this survey is to gather your perceptions about opportunities for physical activity, healthy eating, and tobacco cessation in your community.  The information gathered in this survey will inform our efforts in ensuring that community members have healthy options to choose from.  This survey will be shared with the community once per year for each of the three years of
the Pathways initiative.  Your responses will be compiled with other responses and will never directly identify your individual response.  We are gathering demographic information to ensure that we have gathered outside the project team.  You can choose to skip questions that you don't feel comfortable answering and you can stop at any time.  We thank you for your participation!

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* 1. Part I:  Community Perceptions
General Community Health
In general, how would you rate the overall health of our community?

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* 2. Physical Activity
Please rate your level of agreement with the following statements:

  Strongly Disagree Disagree Neutral Agree Strongly Agree
My community has a sufficient number of sidewalks or bike/walk paths
My community has a sufficient number of parks/playgrounds
For walking at night, my community has adequate street lighting
In general, my community has sufficient opportunities for physical activities

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* 3. Healthy Foods
Please rate your level of agreement with the following statements:

  Strongly Disagree Disagree Neutral Agree Strongly Agree
It is easy to find fresh fruits and vegetables in my community
The fresh produce in my community is of high quality
It is easy to find whole-grain products, such as breads, cereals, pasta and snacks, in my community
In general, my community has sufficient options for healthy eating

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* 4. Tobacco
Are you aware of efforts in your community to promote smoking cessation (i.e. quitting smoking)?

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* 5. Please rate your level of support for policies that prohibit tobacco use (i.e. smoking and chewing tobacco) in the following settings:

  Definitely not supportive Not Supportive Neutral Supportive Very Supportive
Local Parks
School Grounds
Hospital Grounds
Worksites

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* 6. Initiative Awareness
Were you aware of the Pathways to a Healthy Kansas Initiative that is being implemented by the Quality of Life Coalition, Inc. in your community?

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* 7. Part II: Demographics
Where do you live (or closest town in Dickinson County)?

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* 8. Age

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* 9. Gender:

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* 10. Education:

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