Gender:

Question Title

* 1. Gender:

Age Category:

Question Title

* 2. Age Category:

Marital Status:

Question Title

* 3. Marital Status:

How many people live in your household including yourself?

Question Title

* 4. How many people live in your household including yourself?

Race/Ethnic Origin:

Question Title

* 5. Race/Ethnic Origin:

Highest level of school you have completed:

Question Title

* 6. Highest level of school you have completed:

What is your zip code?

Question Title

* 7. What is your zip code?

Are you the primary care giver for any of the following?

Question Title

* 8. Are you the primary care giver for any of the following?

Do you:

Question Title

* 9. Do you:

Do you have any of the following in your home?

Question Title

* 10. Do you have any of the following in your home?

Do you feel safe in your neighborhood?

Question Title

* 11. Do you feel safe in your neighborhood?

What do you think is healthy about our community?

Question Title

* 12. What do you think is healthy about our community?

What do you think is unhealthy about our community?

Question Title

* 13. What do you think is unhealthy about our community?

In the past 12 months, have you or someone you know had difficulty getting needed healthcare?

Question Title

* 14. In the past 12 months, have you or someone you know had difficulty getting needed healthcare?

If you do NOT have health insurance is it because (fill in all that apply):

Question Title

* 15. If you do NOT have health insurance is it because (fill in all that apply):

What do you think is the most pressing health care related need for you, your family or our community?

Question Title

* 16. What do you think is the most pressing health care related need for you, your family or our community?

In the past 12 months, have you had a(n) (fill in all that apply):

Question Title

* 17. In the past 12 months, have you had a(n) (fill in all that apply):

  Yes No I'm Not Sure
General Health exam
Blood pressure check
Cholesterol check
Flu shot
Pneumonia shot
Skin cancer screen
Blood Stool test
Dental exam/teeth cleaned
Breast exam
Mammogram
Diabetes check
Eye exam
Hearing exam
Colon exam
Ultrasound
Stress Test
Biopsy
Surgery
Have you been hospitalized in the last:

Question Title

* 18. Have you been hospitalized in the last:

In what ways do you think the hospital is serving the community well?

Question Title

* 19. In what ways do you think the hospital is serving the community well?

In what ways could the hospital improve the way in which it serves the community?

Question Title

* 20. In what ways could the hospital improve the way in which it serves the community?

What services do you feel are needed in our community that currently do not exist?

Question Title

* 21. What services do you feel are needed in our community that currently do not exist?

Do you see community members working together in collaboration to address community health needs?

Question Title

* 22. Do you see community members working together in collaboration to address community health needs?

What is the number one thing the hospital could do to improve the health and quality of life of the community?

Question Title

* 23. What is the number one thing the hospital could do to improve the health and quality of life of the community?

Any other comments you think are important to address in this survey?

Question Title

* 24. Any other comments you think are important to address in this survey?

T