Community Health Needs Assessment Survey

Mahalo for your participation! Your feedback helps guide the future of health services and programs for our communities.

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1. Are you Native Hawaiian? (Required.)

Yes, I am Native Hawaiian

No, I am not Native Hawaiian, but I have Native Hawaiians in my household

No, I am not Native Hawaiian, and I have no Native Hawaiians in my household

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2. What is your ZIP code? (Required.)

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3. Do you have a regular health care provider? (Required.)

Yes

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4. How would you rate your overall health? (Required.)

Excellent

Good

Fair

Poor

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5. To what extent do you feel you are living in a state of lōkahi (balance and harmony) among your physical body, spirituality, ‘ohana (family), lāhui (community), and the land that sustains you (‘āina)? (Required.)

5 — Completely balanced

4 — Mostly balanced

3 — Somewhat balanced

2 — Slightly balanced

1 — Not at all balanced

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6. In the past 12 months, did you need health care but could not get it? (Required.)

Yes

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7. If yes, what made it difficult to get care? (Check all that apply)

Cost

Lack of Insurance

Transportation

Clinic Hours

Long wait times

Language Barriers

Other (please specify)

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8. Do you currently have medical insurance? (Required.)

Yes

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9. If yes, which health plan do you have?

Kaiser Permanente

HMSA

'Ohana Health Plan

United Health Care

Other (please specify)

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10. Do you have reliable access to healthy foods? (Required.)

Yes

Sometimes

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11. Do you have safe and stable housing? (Required.)

Yes

Sometimes

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12. Do you have reliable transportation to medical appointments? (Required.)

Yes

Sometimes

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13. Which health conditions are of greatest concern to you or your family? (Required.)

Hypertension (High blood pressure)

Diabetes

Weight Management/ Obesity

Cancer

Heart Disease

Substance Use

Mental Health Conditions

Other (please specify)

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14. Which issues have the biggest impact on your community?
(Check all that apply) (Required.)

Homelessness

Drug Use

Alcohol Abuse

Crime

Domestic Violence

Low Income/ Poverty

Overcrowded Housing

Mental Health Concerns

Access to Health Care

Other (please specify)

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15. Which health services are most needed in your community?
(Check all that apply) (Required.)

Primary Care

Dental Care

Mental Health Services

Specialty Care

Substance Use Treatment

Women's Health Services

Keiki/Youth Health Services

Kupuna Services

Opportunities for Cultural Connection

Native Hawaiian Healing Practices

Other (please specify)

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16. Which social services are most needed in your community?
(Check all that apply) (Required.)

Housing Assistance

Transportation Assistance

Food Assistance

Employment Assistance

Financial Assistance

Child Care Support

Health Insurance Enrollment Assistance

Other (please specify)

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17. What is the biggest health concern facing your community today?
Examples: homelessness, drug use, crime, alcohol abuse, violence or domestic violence, low income, and mental health concerns (Required.)

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18. What programs, services, or resources would you like Ke Ola Mamo to provide or expand? (Required.)

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19. Giveaway Entry (Optional)
Please provide your contact information below. This information will be used to contact you if you are selected as a winner for participating in the Survey.

Full Name:
Email Address:
Phone Number:

Community Health Needs Assessment Survey

Question Title

* 1. Are you Native Hawaiian? (Required.)

Question Title

* 2. What is your ZIP code? (Required.)

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* 3. Do you have a regular health care provider? (Required.)

Question Title

* 4. How would you rate your overall health? (Required.)

Question Title

* 5. To what extent do you feel you are living in a state of lōkahi (balance and harmony) among your physical body, spirituality, ‘ohana (family), lāhui (community), and the land that sustains you (‘āina)? (Required.)

Question Title

* 6. In the past 12 months, did you need health care but could not get it? (Required.)

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* 7. If yes, what made it difficult to get care? (Check all that apply)

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* 8. Do you currently have medical insurance? (Required.)

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* 9. If yes, which health plan do you have?

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* 10. Do you have reliable access to healthy foods? (Required.)

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* 11. Do you have safe and stable housing? (Required.)

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* 12. Do you have reliable transportation to medical appointments? (Required.)

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* 13. Which health conditions are of greatest concern to you or your family? (Required.)

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* 14. Which issues have the biggest impact on your community?(Check all that apply) (Required.)

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* 15. Which health services are most needed in your community?(Check all that apply) (Required.)

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* 16. Which social services are most needed in your community?(Check all that apply) (Required.)

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* 17. What is the biggest health concern facing your community today?Examples: homelessness, drug use, crime, alcohol abuse, violence or domestic violence, low income, and mental health concerns (Required.)

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* 18. What programs, services, or resources would you like Ke Ola Mamo to provide or expand? (Required.)

Question Title

* 19. Giveaway Entry (Optional)Please provide your contact information below. This information will be used to contact you if you are selected as a winner for participating in the Survey.Full Name:Email Address:Phone Number:

1. Are you Native Hawaiian? (Required.)

2. What is your ZIP code? (Required.)

3. Do you have a regular health care provider? (Required.)

4. How would you rate your overall health? (Required.)

5. To what extent do you feel you are living in a state of lōkahi (balance and harmony) among your physical body, spirituality, ‘ohana (family), lāhui (community), and the land that sustains you (‘āina)? (Required.)

6. In the past 12 months, did you need health care but could not get it? (Required.)

7. If yes, what made it difficult to get care? (Check all that apply)

8. Do you currently have medical insurance? (Required.)

9. If yes, which health plan do you have?

10. Do you have reliable access to healthy foods? (Required.)

11. Do you have safe and stable housing? (Required.)

12. Do you have reliable transportation to medical appointments? (Required.)

13. Which health conditions are of greatest concern to you or your family? (Required.)

14. Which issues have the biggest impact on your community?
(Check all that apply) (Required.)

15. Which health services are most needed in your community?
(Check all that apply) (Required.)

16. Which social services are most needed in your community?
(Check all that apply) (Required.)

17. What is the biggest health concern facing your community today?
Examples: homelessness, drug use, crime, alcohol abuse, violence or domestic violence, low income, and mental health concerns (Required.)

18. What programs, services, or resources would you like Ke Ola Mamo to provide or expand? (Required.)

19. Giveaway Entry (Optional)
Please provide your contact information below. This information will be used to contact you if you are selected as a winner for participating in the Survey.

Full Name:
Email Address:
Phone Number: