2012 Community Health Needs Assessment Survey. Thanks for your Participation!

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1. What is your Zip code? (Required.)

ZIP:

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2. What is your gender?

a) Male

b) Female

c) Other/Transgender

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3. What is your race?

a) White

b) Black/African American

c) Asian

d) Native Hawaiian/Other Pacific Islander

e) American Indian/Alaska Native

f) Other

g) Two or more races

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4. Are you Hispanic?

a) Yes

b) No

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5. What language do you speak at home?

a) English

b) Spanish

c) German

d) French

e) Vietnamese

f) Korean

g) Chinese

h) Amharic

i) Maay Maay

j) Other

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6. What is your age group?

a) 18-24 years

b) 25-34 years

c) 35-44 years

d) 45-54 years

e) 55-64 years

f) 64 years or older

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7. Have you seen a primary care provider in the past 12 months?

a) Yes

b) No

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8. Have you used the emergency room in the past 12 months for yourself or another adult in your household?

a) 1 to 2 times

b) 3 to 5 times

c) 6 or more times

d) None

e) I don’t know

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9. Have you used the emergency room in the past 12 months for a child under your care?

a) 1 to 2 times

b) 3 to 5 times

c) 6 or more times

d) None

e) I don’t know

f) Not applicable

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10. The last time you had to use the emergency room, what was the reason?

a) Non-emergency issue (rash, prescription refill, etc.)

b) Urgent issue (cut, injury to joint, fever, etc.)

c) Emergency (difficulty breathing, chest pain, seizures)

d) Not applicable

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11. Where do you go when you can’t see your regular healthcare provider?

a) Urgent or Immediate Care Center

b) Clinic in a grocery store or drug store

c) Hospital Emergency Room

d) Over the Counter/Pharmacist

e) Folk Remedy

f) Helpline

g) Health Department

h) See a Chiropractor or alternative source of care

i) Rely upon family member

j) Nothing

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12. When you need to travel for health services, how do you get there?

a) TARC

b) Personal Vehicle (car, motorcycle, bike)

c) Walking

d) Car Pool/Taxi/Share Ride

e) Other

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13. Using the scale below, please check the box for each issue that you think is a big barrier(s) to health care in Louisville Metro/Jefferson County.

	a) Strongly Agree	b) Agree	c) Neither Agree or Disagree	d) Disagree	e) Strongly Disagree	f) No Opinion
1. Doctor’s Office Hours	1. Doctor’s Office Hours a) Strongly Agree	1. Doctor’s Office Hours b) Agree	1. Doctor’s Office Hours c) Neither Agree or Disagree	1. Doctor’s Office Hours d) Disagree	1. Doctor’s Office Hours e) Strongly Disagree	1. Doctor’s Office Hours f) No Opinion
2. Transportation	2. Transportation a) Strongly Agree	2. Transportation b) Agree	2. Transportation c) Neither Agree or Disagree	2. Transportation d) Disagree	2. Transportation e) Strongly Disagree	2. Transportation f) No Opinion
3. Knowing Where to go in a Healthcare Facility	3. Knowing Where to go in a Healthcare Facility a) Strongly Agree	3. Knowing Where to go in a Healthcare Facility b) Agree	3. Knowing Where to go in a Healthcare Facility c) Neither Agree or Disagree	3. Knowing Where to go in a Healthcare Facility d) Disagree	3. Knowing Where to go in a Healthcare Facility e) Strongly Disagree	3. Knowing Where to go in a Healthcare Facility f) No Opinion
4. Cost or Expenses	4. Cost or Expenses a) Strongly Agree	4. Cost or Expenses b) Agree	4. Cost or Expenses c) Neither Agree or Disagree	4. Cost or Expenses d) Disagree	4. Cost or Expenses e) Strongly Disagree	4. Cost or Expenses f) No Opinion
5. Discrimination/Bias	5. Discrimination/Bias a) Strongly Agree	5. Discrimination/Bias b) Agree	5. Discrimination/Bias c) Neither Agree or Disagree	5. Discrimination/Bias d) Disagree	5. Discrimination/Bias e) Strongly Disagree	5. Discrimination/Bias f) No Opinion
6. Health Knowledge	6. Health Knowledge a) Strongly Agree	6. Health Knowledge b) Agree	6. Health Knowledge c) Neither Agree or Disagree	6. Health Knowledge d) Disagree	6. Health Knowledge e) Strongly Disagree	6. Health Knowledge f) No Opinion
7. Health Beliefs	7. Health Beliefs a) Strongly Agree	7. Health Beliefs b) Agree	7. Health Beliefs c) Neither Agree or Disagree	7. Health Beliefs d) Disagree	7. Health Beliefs e) Strongly Disagree	7. Health Beliefs f) No Opinion
8. Insurance Issues	8. Insurance Issues a) Strongly Agree	8. Insurance Issues b) Agree	8. Insurance Issues c) Neither Agree or Disagree	8. Insurance Issues d) Disagree	8. Insurance Issues e) Strongly Disagree	8. Insurance Issues f) No Opinion
9. Stigma	9. Stigma a) Strongly Agree	9. Stigma b) Agree	9. Stigma c) Neither Agree or Disagree	9. Stigma d) Disagree	9. Stigma e) Strongly Disagree	9. Stigma f) No Opinion
10. Culture and Language	10. Culture and Language a) Strongly Agree	10. Culture and Language b) Agree	10. Culture and Language c) Neither Agree or Disagree	10. Culture and Language d) Disagree	10. Culture and Language e) Strongly Disagree	10. Culture and Language f) No Opinion
11. Medicaid Rules	11. Medicaid Rules a) Strongly Agree	11. Medicaid Rules b) Agree	11. Medicaid Rules c) Neither Agree or Disagree	11. Medicaid Rules d) Disagree	11. Medicaid Rules e) Strongly Disagree	11. Medicaid Rules f) No Opinion
12. Fear of Deportation	12. Fear of Deportation a) Strongly Agree	12. Fear of Deportation b) Agree	12. Fear of Deportation c) Neither Agree or Disagree	12. Fear of Deportation d) Disagree	12. Fear of Deportation e) Strongly Disagree	12. Fear of Deportation f) No Opinion

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14. When I need health information, most often I rely upon the following source:

a) Family and Friends

b) Media (i.e., TV, radio, newspaper)

c) Internet

d) Health Department

e) Hospital Staff

f) Doctor or Personal Physician

g) Nurse, Nurse Practitioner, Physician Assistant

h) Other

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15. Do you have access to preventive health services (i.e., vaccination/shots, family planning, mammography or any other screenings, etc.)?

a) Yes

b) No

c) I don’t know

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16. When you visit a health care facility for services do you feel you have enough information to know what to expect?

a) Yes

b) No

c) Not applicable

d) I don’t know

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17. The last time you came home from a healthcare facility, did you feel that discharge instructions were clear enough for you and your family to help you recover?

a) Yes

b) No

c) Not applicable

d) I don’t know

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18. Do you feel that health providers provide you with the education and resources you may need?

a) Yes

b) No

c) Not applicable

d) I don’t know

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19. How often do you feel that when you have a medical appointment (i.e. diagnostic test, medical exam, doctor’s visit) you are seen in a timely manner during your visit?

a) Always

b) Usually

c) Sometimes

d) Rarely

e) Never

f) No Opinion

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20. Is ADDICTION a big health problem in your neighborhood? If so, what type? (Please choose one answer)

a) Smoking/Tobacco Use

b) Drug Abuse

c) Alcoholism

d) a and b

e) b and c

f) a and c

g) All of the above

h) None

i) No opinion/I don't know

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21. Is MENTAL ILLNESS a big health problem in your neighborhood? If so, what type? (Please choose one answer)

a) Anxiety

b) Depression

c) Bipolar Disorder

d) a and b

e) b and c

f) a and c

g) All of the above

h) None

i) No opinion/I don't know

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22. Is RESPIRATORY ILLNESS a big health problem in your neighborhood? If so, what type? (Please choose one answer)

a) Asthma

b) COPD (Chronic Obstructive Pulmonary Disease)

c) Emphysema

d) a and b

e) b and c

f) a and c

g) All of the above

h) None

i) No opinion/I don't know

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23. Is CANCER a big health problem in your neighborhood? If so, what type? (Please choose one answer)

a) Lung

b) Breast

c) Prostate

d) a and b

e) b and c

f) a and c

g) All of the above

h) None

i) No opinion/I don't know

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24. Is one of the following types of CHRONIC DISEASE a big health problem in your neighborhood? If so, what type? (Please choose one answer)

a) Diabetes/High Blood Sugar

b) Heart Disease (High Blood Pressure or Heart Attacks)

c) Stroke

d) a and b

e) b and c

f) a and c

g) All of the above

h) None

i) No opinion/I don't know

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25. Are other EMERGING ISSUES a big health problem in your neighborhood? If so, what type? (Please choose one answer)

a) Obesity

b) HIV/AIDS

c) All of the above

d) Other

e) None

f) No opinion/I don't know

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26. Do you feel the various health organizations in your community are meeting the health and wellness needs of your community?

a) Yes

b) No

c) Not applicable

d) I don’t know

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27. Do you think there are people in your community that need care but cannot get it?

a) Yes

b) No

c) Not applicable

d) I don’t know

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28. In your opinion, what is the best way to address the health needs of people in your community? Please choose one option.

a) Availability of health screenings (i.e., cancer screenings)

b) More places to exercise

c) Access to fresh fruit and vegetables

d) Quit smoking classes

e) Diabetes management classes

f) More access to primary care physicians

g) More access to specialists

h) Nutrition education

i) Lower cost of health care and prescription drugs

j) No opinion/I don’t know

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29. How can community/business leaders and heath care organizations work together to meet wellness goals? Please choose one option.

a) Provide more education or prevention programs

b) Provide more health care facilities or doctor/physician’s offices

c) Provide more doctors/physicians

d) Easier access to health care services

e) More funding for reduced cost or free services

f) Provide health coach or navigators

g) Advocate for better health policy

h) No opinion/I don’t know

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30. Which group do you feel needs the most help with access to health care?

a) Children and Teens

b) Young Adults

c) Immigrant and Refugees

d) Minority Groups (i.e., African-American, Hispanic)

e) Elderly

f) Lesbian, Gay, Bisexual and Transgender (LGBT)

g) Physically or Mentally Disabled

h) Low-Income Families

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31. In order to improve children’s health in Louisville Metro/Jefferson County what do we need to do?

a) Increase access to oral health services

b) Increase opportunities for more exercise

c) Increase access to fresh fruit and vegetables

d) Increase availability of special health care needs

e) Increase access to mental and emotional health services

f) More school nurses or school-based health centers

g) Increase access to immunization services

h) Increase health insurance coverage

i) No opinion/I don’t know

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* 1. What is your Zip code? (Required.)

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* 2. What is your gender?

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* 3. What is your race?

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* 4. Are you Hispanic?

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* 5. What language do you speak at home?

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* 6. What is your age group?

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* 7. Have you seen a primary care provider in the past 12 months?

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* 8. Have you used the emergency room in the past 12 months for yourself or another adult in your household?

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* 9. Have you used the emergency room in the past 12 months for a child under your care?

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* 10. The last time you had to use the emergency room, what was the reason?

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* 11. Where do you go when you can’t see your regular healthcare provider?

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* 12. When you need to travel for health services, how do you get there?

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* 13. Using the scale below, please check the box for each issue that you think is a big barrier(s) to health care in Louisville Metro/Jefferson County.

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* 14. When I need health information, most often I rely upon the following source:

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* 15. Do you have access to preventive health services (i.e., vaccination/shots, family planning, mammography or any other screenings, etc.)?

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* 16. When you visit a health care facility for services do you feel you have enough information to know what to expect?

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* 17. The last time you came home from a healthcare facility, did you feel that discharge instructions were clear enough for you and your family to help you recover?

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* 18. Do you feel that health providers provide you with the education and resources you may need?

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* 19. How often do you feel that when you have a medical appointment (i.e. diagnostic test, medical exam, doctor’s visit) you are seen in a timely manner during your visit?

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* 20. Is ADDICTION a big health problem in your neighborhood? If so, what type? (Please choose one answer)

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* 21. Is MENTAL ILLNESS a big health problem in your neighborhood? If so, what type? (Please choose one answer)

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* 22. Is RESPIRATORY ILLNESS a big health problem in your neighborhood? If so, what type? (Please choose one answer)

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* 23. Is CANCER a big health problem in your neighborhood? If so, what type? (Please choose one answer)

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* 24. Is one of the following types of CHRONIC DISEASE a big health problem in your neighborhood? If so, what type? (Please choose one answer)

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* 25. Are other EMERGING ISSUES a big health problem in your neighborhood? If so, what type? (Please choose one answer)

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* 26. Do you feel the various health organizations in your community are meeting the health and wellness needs of your community?

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* 27. Do you think there are people in your community that need care but cannot get it?

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* 28. In your opinion, what is the best way to address the health needs of people in your community? Please choose one option.

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* 29. How can community/business leaders and heath care organizations work together to meet wellness goals? Please choose one option.

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* 30. Which group do you feel needs the most help with access to health care?

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* 31. In order to improve children’s health in Louisville Metro/Jefferson County what do we need to do?

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* 32. What did we miss or not ask you about health related issues in our county? Please comment..

1. What is your Zip code? (Required.)

2. What is your gender?

3. What is your race?

4. Are you Hispanic?

5. What language do you speak at home?

6. What is your age group?

7. Have you seen a primary care provider in the past 12 months?

8. Have you used the emergency room in the past 12 months for yourself or another adult in your household?

9. Have you used the emergency room in the past 12 months for a child under your care?

10. The last time you had to use the emergency room, what was the reason?

11. Where do you go when you can’t see your regular healthcare provider?

12. When you need to travel for health services, how do you get there?

13. Using the scale below, please check the box for each issue that you think is a big barrier(s) to health care in Louisville Metro/Jefferson County.

14. When I need health information, most often I rely upon the following source:

15. Do you have access to preventive health services (i.e., vaccination/shots, family planning, mammography or any other screenings, etc.)?

16. When you visit a health care facility for services do you feel you have enough information to know what to expect?

17. The last time you came home from a healthcare facility, did you feel that discharge instructions were clear enough for you and your family to help you recover?

18. Do you feel that health providers provide you with the education and resources you may need?

19. How often do you feel that when you have a medical appointment (i.e. diagnostic test, medical exam, doctor’s visit) you are seen in a timely manner during your visit?

20. Is ADDICTION a big health problem in your neighborhood? If so, what type? (Please choose one answer)

21. Is MENTAL ILLNESS a big health problem in your neighborhood? If so, what type? (Please choose one answer)

22. Is RESPIRATORY ILLNESS a big health problem in your neighborhood? If so, what type? (Please choose one answer)

23. Is CANCER a big health problem in your neighborhood? If so, what type? (Please choose one answer)

24. Is one of the following types of CHRONIC DISEASE a big health problem in your neighborhood? If so, what type? (Please choose one answer)

25. Are other EMERGING ISSUES a big health problem in your neighborhood? If so, what type? (Please choose one answer)

26. Do you feel the various health organizations in your community are meeting the health and wellness needs of your community?

27. Do you think there are people in your community that need care but cannot get it?

28. In your opinion, what is the best way to address the health needs of people in your community? Please choose one option.

29. How can community/business leaders and heath care organizations work together to meet wellness goals? Please choose one option.

30. Which group do you feel needs the most help with access to health care?

31. In order to improve children’s health in Louisville Metro/Jefferson County what do we need to do?

32. What did we miss or not ask you about health related issues in our county? Please comment..