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Thank you for participating in the survey. Every three years the Healthy Klamath Network produces a Klamath County Community Health Assessment. It provides a look at how the county is doing in areas related to health. The information is used to create a community health improvement plan (CHIP). The information you share is anonymous and you may decline to answer any question that feels too personal to answer. All answers are used to learn more about the community and understand where improvement can happen. In this survey “healthcare” includes medical, dental, mental health, and substance use services and treatment.

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* 1. Where in Klamath County do you live?

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* 2. In general, would you say your health is:

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* 3. Do you find public transportation easy to use?

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* 4. In the past 12 months, have you worried that your food would run out before you got money to buy more?

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* 5. What is your housing situation today?

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* 6. Have you been affected by natural disasters in the last 12 months? Check all that apply.

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* 7. Do you have easy access to clean drinking water?

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* 8. In the past 12 months have you been sick or injured as a result of indoor temperatures of 80 degrees or above?

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* 9. In the past 12 months have you been sick or injured as a result of outdoor temperatures of 80 degrees or above?

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* 10. In the past 12 months have you been sick or injured as a result of indoor temperatures of 40 degrees or lower?

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* 11. In the past 12 months have you been sick or injured as a result of outdoor temperatures of 40 degrees or lower?

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* 12. Do you have a way to heat your home? Select all that apply.

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* 13. Do you consider heating your home to be affordable?

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* 14. Do you have a way to cool air in your home when it is hot outside? Select all that apply.

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* 15. Which environmental factors have you thought about most in the past 12 months related to your overall health and well-being? Select all that apply.

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* 16. In the past 12 months, have you used any of the following services? Check all that apply.

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* 17. If you selected Emergency room (ER) why did you visit the ER? Check all that apply.

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* 18. In the past two (2) years, have you had to travel out of Klamath to receive needed medical services?

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* 19. In the past two (2) years, have you received primary care from a provider who doesn't have an office location in Klamath?

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* 20. Have any of the following prevented you or a loved one from getting health care (medical, dental, mental health, or substance use treatment) in the past year? Check all that apply.

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* 21. What prevented you from following a provider’s follow-up orders, such as prescriptions, blood tests or imaging (x-ray, MRI, ultrasound)?

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* 22. If there was an issue that kept you from using health care services, which of the following were you unable to use? Check all that apply.

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* 23. In the past 30 days have you had a medical, dental, mental health, or substance use service appointment you missed or skipped?

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* 24. Are you offered extended hours or same-day appointments by your healthcare provider?

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* 25. Do you utilize extended hours or same-day appointments by your health care provider?

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* 26. Would you prefer virtual (computer, smartphone, tablet) care?

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* 27. Are there concerns that may prevent you from using virtual (computer, smartphone, tablet) care? Check all that apply.

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* 28. What other types of care might help you or your loved ones? Select all that apply.

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* 29. In the past 30 days, how often did mental health concerns (such as depression, anxiety or other mental health issues) make it hard for you to do your usual activities, such as self-care or work?

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* 30. In the past 30 days, how often did physical pain make it hard for you to do your usual activities, such as self-care or work?

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* 31. In the past 30 days, how often did substance use impact your relationships, daily life, or work?

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* 32. If you are a member of Cascade Health Alliance (Oregon Health Plan), have you been offered case management?

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* 33. Is there anything you feel is keeping you from having better health? Check all that apply.

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* 34. Do you or a loved one have behavioral health concerns (mental health and/or substance use)?

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* 35. Do you or a loved one get behavioral health (mental health and/or substance use treatment) services?

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* 36. What times do you prefer to access behavioral health (mental health and/or substance use treatment) services? Check all that apply.

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* 37. Where do you prefer to access behavioral health (mental health and/or substance use treatment) services? Check all that apply.

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* 38. Are you or your loved one able to get behavioral health (mental health and/or substance use treatment) services from someone who is similar to you?

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* 39. If you or your loved one wanted to engage in behavioral health services (mental health and/or substance use treatment), would you know how to access those services?

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* 40. Have you or your loved one had difficulty accessing behavioral health (mental health and/or substance use treatment) services? Check all that apply.

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* 41. Has anyone reached out to you or a loved one to begin or continue behavioral health (mental health and/or substance use) treatment?

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* 42. What areas of life do you or your loved one need the most help in? Check all that apply

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* 43. Are you a veteran, or currently in the military?

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* 44. Do you or a loved one want to quit any of the following: Check all that apply

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* 45. If you have a school-aged child, and if the child did not go to school regularly, do you think their learning would be affected:

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* 46. If you have a school-aged child, for what reasons would you keep your child out of school? Check all that apply.

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* 47. Are you satisfied with the city or area where you live?

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* 48. As a place to live, is the city or area where you live getting:

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* 49. How responsive is local government to the needs of residents?

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* 50. The job done by the police to keep residents safe is:

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* 51. The ability of residents to obtain suitable employment is:

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* 52. How is the city or area where you live as a place to raise children?

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* 53. How are the condition of public parks and other public recreational facilities?

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* 54. What is your age?

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* 55. What is the highest level of education you completed?

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* 56. How many people usually live in your household?

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* 57. What is your yearly household income?

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* 58. Do you have health insurance?

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* 59. If you have insurance, what kind do you have?

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* 60. What is your employment status? (Check all that apply)

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* 61. What is your gender identity? Check all that apply.

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* 62. Are you transgender?

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* 63. How would you describe your sexual orientation or sexual identity? Check all that apply.

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* 64. How do you identify your race, ethnicity, tribal affiliation, country of origin or ancestry?

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* 65. Which of the following describes your racial or ethnic identity? Please check all that apply.

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* 66. Select all of the languages spoken in your home:

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