Thank you for taking the time to take this survey. This survey will help to give a voice to the problems you see in your community that affect health and help us to address them properly.

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* 1. What would you say are big problems that need to be addressed in your community to improve your community’s health? (Rank your top five choices by 1=Most important, 2= Second most important, 3=Third most important, 4=Fourth most important, 5= Fifth most important)

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* 2. If you chose other please specify:

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* 3. What would you say are big problems that need to be addressed in the community to improve your individual health? (Rank your top five choices by 1=Most important, 2= Second most important, 3=Third most important, 4=Fourth most important, 5= Fifth most important)

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* 4. If you chose other please specify:

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* 5. What are some of the concerns you have about your health? (Click all that apply)

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* 6. Where do you most often go to when you are sick or need advice about your health care?

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* 7. How would you rate your health?

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* 8. What way is the best way for you to address the problem in the community to improve quality of life? (Rank your top three choices by 1=Most important, 2= Second most important, 3=Third most important)

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* 9. If you chose other please specify:

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* 10. What types of health information would you like to learn more about?(click all that apply) (Click all that apply)

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* 11. What is your sex?

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* 12. What is your age?

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* 13. What is your race/ethnicity?

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* 14. What is your zip code?

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* 15. Which of these categories best describes your total combined family income for your household for the past 12 months? This should include income (before taxes) from all sources, wages, rent from properties, social security, disability and/or veteran’s benefits, unemployment benefits, workman’s compensation, help from relatives (including child payments and alimony), and so on.

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