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* 1. What county do you live in?

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* 2. What is the zip code where you live?

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* 3. What is your biological sex?

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* 4. What is your age?

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* 5. What race do you identify as?

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* 7. What is your household income?

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* 8. In your household, how many children under the age of 18 are you the main caretaker of?

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* 9. What is the primary language spoken in your household?

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* 10. In your opinion and experience, what are the greatest strengths of Delaware County? (Check all that apply)

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* 11. In your opinion and experience, what are the greatest health-related concerns facing Delaware County? (Check all that apply)

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* 12. How healthy would you say your eating habits are?

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* 13. How important is eating healthy for you and/or your family?

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* 14. How stressful is it for you to afford healthy food?

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* 15. Where do you most often get your food? (Check all that apply)

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* 16. How long does it take for you to get to your usual location for food shopping?

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* 17. How do you normally travel to shop for food?

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* 18. How many days a week are you physically active for 20-30 minutes? (either through work or voluntarily)

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* 19. How important is physical activity to you?

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* 20. How would you rate your community as a place for children to play outdoors?

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* 21. How would you rate your community for after school activities for children and families?

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* 22. How would you rate your community as a place for adults to walk and keep active?

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* 23. Do you currently use any of the following tobacco/nicotine products? (Check all that apply)

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* 24. If you do use tobacco product(s), are there any barriers that prevent you from quitting smoking? Please describe.

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* 25. Do you have health insurance? 

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* 26. If you have health insurance, which type of plan do you have?

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* 27. Was there any time in the past year that you needed medical or dental care but could not, or did not get it?

  Yes No
Medical 
Dental

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* 28. If you could not or did not access the care you needed, what prevented you?

  Cost  Lack of insurance Transportation problems  No time/could not get off work No provider close enough I dislike going to my provider Medical problem went away on its own
Medical 
Dental

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* 29. Do you have a doctor in Delaware County that you see regularly?

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* 30. Do you have difficulty getting to a specialty doctor or surgeon (such as a cardiologist for heart or an orthopedist for bone) when you need one?

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* 31. What specialty did/do you need?

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* 32. If you have seen a specialist, how how much time did you spend traveling to them?

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* 33. On a monthly basis, are you stressed when trying to afford any of the following? (Check all that apply)

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* 34. Have you ever seen or experienced violence in your community?

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* 35. How safe do you feel from violence in your home?

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* 36. Where does most of your drinking water come from?

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* 37. How confident are you in the safety of food handling and preparation in Delaware County?

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* 38. Do you feel the lack of maternity care and a birthing hospital that delivers babies in Delaware County affects women's and children's health?

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* 39. How effective is the education of pregnancy risks, cancer screenings and Sexually Transmitted Infection prevention education in Delaware County?

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* 40. Do you feel that most parents in Delaware County are aware of the benefits of breastfeeding? 

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* 41. Does your community offer enough low-income housing options?

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* 42. Does your community offer enough middle-income housing options?

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* 43. Do you think that most people in your community have a safe and affordable place to live? 

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* 44. In the past year, have you or someone close to you experienced any of the following? (Check all that apply)

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* 45. Were you, or someone close to you, able to receive help or treatment for the concern(s) you chose above?

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* 46. What was the barrier that prevented you or someone close to you from getting help?

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* 47. Do you feel that people in Delaware County have a generally acceptable attitude towards vaccines?

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* 48. How important is it to stop vaccine-preventable disease (Hepatitis A/Measles/Mumps/Rubella etc.) in Delaware County?

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* 49. How important is it to prevent the spread of Human Immunodeficiency Virus (HIV) in Delaware County?

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* 50. How important is it to prevent the spread of Sexually Transmitted Infections (STIs) through education, treatment, and vaccinations in Delaware County?

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* 51. We will be holding a Community Roundtable Discussion on May 30 at SUNY Delhi from 9-12 to go over the results of this survey and to gather input on next steps. If you would like to receive an invitation to that meeting, please include your contact information, here! 

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