Grafton City Hospital is conducting a Community Health Needs Assessment (CHNA) Survey. By answering these questions, you will help us identify the most important health needs in your community. The information obtained from the CHNA will be used in the development of an action plan to improve the health of local community members.

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* 1. In what ZIP code is your home located? (enter 5-digit ZIP code; for example, 26354)

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* 2. Have you or someone in your household used the services of Grafton City Hospital in the past 24 months?

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* 3. If not at Grafton City Hospital, at which hospital(s) were services rendered?

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* 4. Why did you or someone in your household receive care at a hospital other than Grafton City Hospital?

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* 5. What services do you use at Grafton City Hospital? (Select all that apply)

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* 6. On a scale of 1-5 (1 - extremely dissatisfied, 5 - extremely satisfied), how satisfied were you or someone in your household with the services you received at Grafton City Hospital?

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* 7. Please explain why you were satisfied or dissatisfied.

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* 8. What type of specialist(s) have you or someone in your household been to in the past 24 months?

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* 9. In what city did you consult with the specialist?

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* 10. How much of a barrier are the following to receiving assistance for your needs?

  Not a barrier A small barrier A major barrier
Can not afford fees/cost of assistance
Not eligible or do not qualify for assistance
No transportation prevents me from obtaining assistance
No childcare prevents me from obtaining assistance
Do not know where to go for assistance
Do not want to ask for assistance
Assistance is not in my area
Prior bad experience with obtaining assistance
Have to work during business hours of assistance provider
Health or disability prevents me from seeking assistance

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* 11. Do you have any of the following residents living in your household?

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* 12. Did you received dental care in the past 12 months?

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* 13. If applicable, what barrier(s) prevent you from seeing a dentist?

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* 14. What is your employment status?

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* 15. Do you and/or your family have a primary care/family doctor?

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* 16. If yes, are you able to get an appointment with your primary care physician when needed?

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* 17. Where is your primary care physician/family doctor located?

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* 18. How satisfied were you or someone in your household with the quality of care received at your primary care physician's office?

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* 19. If no, then what kind of medical provider do you use for routine care?

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* 20. Have you or someone in your household delayed health care due to lack of money and/or insurance?

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* 21. Do you or anyone in your household have any of the following conditions? (Select all that apply)

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* 22. Please check the three most important services which should be added or expanded within the Grafton City Hospital service area? (select no more than 3)

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* 23. Please select your primary insurance carrier or provider (select only one):

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* 24. What is your age?

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* 25. What is your gender?

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* 26. What is your marital status?

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* 27. What is your race?

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* 28. How many people currently live in your household?

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* 29. What is your approximate annual household income?

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* 30. What is the highest level of education have you completed?

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* 31. Do you have any other thoughts on the level and variety of care provided in the community or by Grafton City Hospital?

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