* 1. Gender:

* 2. Age Category:

* 3. Marital Status:

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

* 5. Race/Ethnic Origin:

* 6. Highest level of school you have completed:

* 7. What is your zip code?

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

* 9. Do you:

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

* 11. Do you feel safe in your neighborhood?

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

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

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

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

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

* 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
Diabetes check
Eye exam
Hearing exam
Colon exam
Stress Test

* 18. Have you been hospitalized in the last:

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

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

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

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

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

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