Thank you for completing our survey!

Hills & Dales General Hospital is conducting a community survey to assess the health care needs in our communities. Your response is anonymous, and you may skip any question (after #1) that you do not want to answer. If you have any questions about this survey, you may call our Public Relations Department at (989)912-6401. Surveys will be collected until May 31, 2019.

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* 1. Are you at least 18 years of age or older?

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* 2. What is your ZIP code?

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* 3. What is your gender?

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* 4. Do you identify as a member of a racial or ethnic minority group?

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

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* 6. What is your age?

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* 7. How many children (under 18 years old) live in your household?

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* 8. Including yourself, how many senior citizens (age 65 years and over) live in your household?

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* 9. Are you a caregiver for a child or adult who has serious or complex medical needs?

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* 10. Do you or anyone in your household have a disability?

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

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* 12. In the last 12 months, have you or anyone in your household received services from Hills & Dales General Hospital? (check all that apply)

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* 13. Did you know that Hills & Dales General Hospital has a Financial Assistance Program to help people based on their income and needs?

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* 14. In the last 12 months, have you or someone in your household delayed or gone without health care for any of the following reasons? (Choose all that apply.)

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* 15. Are there any new services or specialties that you wish were available through Hills & Dales General Hospital?

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* 16. Are there any new services or resources that you wish were available in your community?

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* 17. Are any of the following a problem in the community where you live? (Choose all that apply.)

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* 18. Are any of the following a health care need in your community? (Choose all that apply.)

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* 19. Are any of the following a problem for you or anyone in your household? (Choose all that apply.)

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* 20. How do you usually get information about services, providers or events at Hills & Dales General Hospital? (Choose all that apply.)

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