* 1. What is your Zip Code

* 2. How many people live in your household?

* 3. What is your gender?

* 4. What is your age?

* 5. Which race/ethnicity best describes you? (Please choose only one.)

* 6. What language do you mainly speak at home?

* 7. What is the highest level of school you have completed or the highest degree you have received?

* 8. What is your approximate average household income?

* 9. Do you have sufficient access to food, shelter, clothing and medical care year round?

* 10. From the list below, please check THREE items that you think are the most important health concerns for Clayton County to address in the next 3-5 years

* 11. From the list below, please check THREE behaviors that you think have the greatest impact on overall community health?

* 12. From the list below, please check THREE environmental hazards that you feel are needs that should be addressed in our community in the next 3-5 years.

* 13. Please select up to THREE of the most important barriers that you believe keep people in our community from accessing healthcare.

* 14. From the list below, please choose what you think is the most important preventable accident in Clayton County that needs more public education?

* 15. Using a scale from Strongly Agree to Strongly Disagree, please rate these statements about Health Care Access in our community:

  Strongly Agree Agree Neither Disagree or Agree Disagree Strongly Disagree
Most residents in my community are able to access a primary care provider (family doctor, pediatricians, general practitioner) when needed.
Most residents in my community are able to access a medical specialist (cardiologist, dermatologist, neurologist, etc..) when needed.
Most residents in my community are able to obtain prescription medications when needed.
People new to my community know how to get healthcare.

* 16. Using a scale from Strongly Agree to Strongly Disagree, please rate these statements about Health Care Access in our community:

  Strongly Agree Agree Neither Agree or Disagree Disagree Strongly Disagree
I am aware of resources that can help me obtain insurance if I do not get it from my employer.
There are enough healthcare providers who accept all forms of insurance in my community.
There are enough healthcare providers that accept Medicaid or other forms of medical assistance in my community.

* 17. Using a scale from Strongly Agree to Strongly Disagree, please rate these statements about Health Care Access in our community:

  Strongly Agree Agree Neither Agree or Disagree Disagree Strongly Disagree
Most residents in my community are able to access mental health resources in times of need.
There are enough bilingual healthcare providers in my community.
There is access to caregiver support and resources in Clayton County (ex. respite care)
There are resources available if a family is in need of food or nutrition.
There are resources available if a family has spiritual health needs.

* 18. Over the past 3-5 years, what would you say are the most significant improvements in our community that have improved health and well-being?

* 19. Please describe any other health needs that you feel should be addressed in the next 3-5 years in our community.

* 20. What do you see as barrier to prevent our community from becoming healthier?

* 21. What education would you like to see provided in the community in regards to health or prevention?

* 22. Do you have any other comments, questions, or concerns?

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