THIS SURVEY IS COMPLETELY ANONYMOUS.

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100% of survey complete.
F.W. Huston Medical Center, Jefferson County Health Department Home Health and Hospice, and the Jefferson County Alliance of Service Councils are conducting a Community Health Needs Assessment to determine the community and health-related issues in Jefferson County. Your participation is vital to the advancement and development of the county’s economy and health care services. You will help us identify the most important health needs in Jefferson County according to the people who live here so that we can focus our efforts in ways that will best serve our county.

Please take a few moments to fill out this survey for you and your household. Household is defined for this survey as you, your partner, and dependents including children <26 years of age.  (Children <26 years of age are included in your household even if they do not live in your home.)  

For questions 26-30, PLEASE ONLY COMPLETE THE CONCERNS THAT ARE APPLICABLE TO YOU AND YOUR HOUSEHOLD.  Please check the concerns you have including conditions for which you or someone in your household is being treated, even if it is a well-controlled condition.
Thank you for completing the survey!

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1. In what zip code is your place of residence?

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2. What is your age?

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3. What is your identifying gender?

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4. Choose one ethnic identity.

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5. Choose one or more racial identities (regardless of ethnicity).

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6. Please choose which of the following applies to you:

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7. Indicate your annual take home pay range.

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8. How many people live in your household?

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9. Of those people identified in the above question, how many are dependents?

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10. Does anyone in your household receive disability benefits?

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12. I use these services within Jefferson County more than 50% of the time. (select all that apply)

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13.

What television station(s) do you get your news from? (select all that apply)

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14. How do you stay up to date with current events and news? (select all that apply)

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15. What newspaper(s) do you read? (select all that apply)

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16. If jobs were available in Jefferson County in your industry, would you work in Jefferson County?

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18. How would you describe your overall health?

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19. Do you have a Primary Care Provider

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20. If you have a Primary Care Provider, are they located in Jefferson County?

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21. Are you able to visit a health care provider (Doctor, Nurse Practitioner, Physician's Assistant) when needed in Jefferson County?

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22. If you answered "NO" to question #21, choose all that apply.

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23. What type of healthcare coverage do you have?

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24. What type of healthcare coverage do your dependents have?

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25. FOR ALL SURVEY RESPONDENTS:  
I am concerned about the following for ANYONE in my household:

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26. Young Children:  Birth-to-5 years
 
I am concerned about the following in my household:

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27. Children/Teen:  6 years - 18 years
 
I am concerned about the following in my household:

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28. Young Adulthood:  18 years - 35 years
 
I am concerned about the following in my household:

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29. Middle Adulthood:  36 years - 64 years
 
I am concerned about the following in my household:

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30. Older Adulthood:  65+ years
 
I am concerned about the following in my household:

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31. Other Comments:

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