Please take a few minutes to complete the survey below.

The purpose of this survey is to get your opinions about health issues in our community. This survey is conducted by the Alliance for a Healthier Effingham County & Jasper County Steering Committee and Effingham and Jasper County Health Departments in partnership with HSHS St. Anthony’s Memorial Hospital.  The results of this survey along with other information will be used for the development of a community health improvement plan for the county in which you reside.  Your opinion is important to us! Thank you!      

***Note - This survey is anonymous

Part 1: Community Health

* 1. In the following list, what do you think are the three most important factors for a healthy community?  (Those factors which most improve the quality of life in a community.)

Check only three (3):

* 2. In the following list, what do you think are the three most important health problems in our community?  (Those problems which have the greatest impact on overall community health.)

Check only three (3):

* 3. In the following list, what do you think are the three most important risky behaviors in our community? (Those behaviors which have the greatest impact on overall community health.)

Check only three (3):

* 4. How would you rate our community as a “Healthy Community?”

* 5. How would you rate your own personal health?

Part 2: Housing

* 6. How often in the past 12 months would your household say they were worried or stressed about having enough money to pay your rent/mortgage? Would you say you were worried or stressed-

* 7. Do you feel your home is currently physically safe to live in?

* 8. If No, why not? Choose all that apply

Part 3 - Health Status

* 9. How often do you seek medical attention?

* 10. What is the most significant barrier for seeking medical attention for you and or your family? (Choose all that apply.)

* 11. How do you pay for your health care?

* 12. Do you have one person / clinic you think of as your primary health care provider?

* 13. Do you or does any member of your household currently use…… (Choose all that apply.)

Part 4: Mental Health Status

* 14. Thinking about your mental health, which includes stress, depression, and problems with emotions, for how many days during the past 30 days was your mental health not good?

Part 5: Oral Health Status

* 15. How would you rate your oral health status?

* 16. Do you have a regular dental provider?

* 17. What is the most significant barrier to seeking regular dental care? (Choose all that apply)

* 18. How do you pay for you and your family's dental care?

Part 6 - Drug Abuse

* 19. How concerned are you with prescription drug abuse in your community?

* 20. How concerned are you with illegal drug use in your community?

Part 7 - Alcohol Use

* 21. During the past 30 days, how many days per week did you have at least one drink of any alcoholic beverage such as beer, wine, a malt beverage or liquor?

* 22. Considering all types of alcoholic beverages, how many times during the past 30 days did you have 4 or more drinks on one occasion?

Part 8 - Nutrition and Exercise

* 23. How many times a week do you exercise?

* 24. How often in the past 12 months would your household say they were worried or stressed about having enough money to buy food? Would you say you were worried or stressed - 

* 25. During the past month, not counting juice, how many times did you eat fruit?

* 26. During the past month, how many times did you eat vegetables?

* 27. Are you satisfied with the quality of life in our community? (Consider your sense or safety, well-being, participation in community life and associations, etc.)

* 28. Is there economic opportunity in the community? (Consider locally owned and operated businesses, jobs with career growth, job training/higher education opportunities, affordable housing, reasonable commute, etc.)

* 29. Do you feel the community is a safe place to live? (Consider resident's perceptions of safety in the home, the workplace, schools, playgrounds, parks, and the mall. Do neighbors know and trust one another? Do they look out for one another?)

* 30. Does the community offer networks of support for individuals and families during times of stress and need? (such as neighbors, support groups, faith community outreach, agencies, organizations)

Part 9 - Emergency Preparedness

* 31. Has your household prepared an Emergency Supply Kit with supplies like water, food, flashlights, and extra batteries that is kept in a designated place in your home?

* 32. Does your household have any emergency plans, such as a list of emergency contact numbers and designated out-of-town contacts, designated meeting place, copies of important documents in a safe location?

* 33. Does your household currently have a 7 day supply of medication for each person who takes prescribed meds?

* 34. Where would you first look for reliable information regarding a disaster?

Part 10 - Demographics

* 35. Zip Code of City/Village where you live

* 36. Age

* 37. Sex

* 38. Ethnic group you most identify with

THANK YOU FOR YOUR TIME!

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