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* 1. How long have you been a resident of this community?

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* 2. About how many people in your community do you know well enough to ask for a favour?

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* 3. How many close friends or relatives do you feel at ease with, can talk to about what is on your mind, or can call on for support?

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* 4. Do you feel your community is a good place to grow old?

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

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

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* 7. How many servings of fruits and vegetables do you eat most days? (1 serving = ½ cup of fruit or vegetables)

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* 8. How often do you exercise per week? For example, biking, walking, swimming, etc?

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* 9. On average how many minutes a day do you spend on physical activity that gets your heart rate up?

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* 10. How would you describe your level of stress?

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* 11. How many days last month did a mental health problem or an emotional problem (your mood, your feelings) stop you from doing your work or other usual activities?

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* 12. How easy is it for you to get the services you need? Rate the overall accessibility of health care services. (Questions 12-21).
Your doctor or nurse practitioner

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* 13. Diagnostic services such as x-ray, ultrasound or lab

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* 14. Rehab services such as physiotherapy

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* 15. Complementary health practitioners such as: naturopaths, chiropractors

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* 16. Programs to help manage a chronic condition such as diabetes or arthritis

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* 17. Dental care

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* 18. Home health support such as assistance with household tasks

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* 19. Home health care such as nursing or physiotherapy

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* 20. Mental health services such as counselling, mental health support

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* 21. Addictions services such as counseling, Alcoholics Anonymous

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* 22. Family violence prevention support

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* 23. In the past 12 months did you volunteer for a community organization or group, either within the community or outside your community (Questions 22-26).
Service club such as: Lions, Optimists

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* 24. Community agency

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* 25. Church council or church committee

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* 26. School

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* 27. Here at Langs

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* 28. Other, please list.

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* 29. Do decision-makers in your community respect differing opinions raised by local residents.

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* 30. I am satisfied with the health of the environment in my community.

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* 31. What is the environmental issue you are most concerned about? (please check one)

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* 32. How safe do you feel in your community doing the following

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* 33. Walking

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* 34. Cycling

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* 35. Driving/passenger in a car/van

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* 36. On public transportation

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* 37. Letting children play outside

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* 38. Are your reading, writing and math skills good enough for you to do the following:

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* 39. Read medication instructions

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* 40. Complete a job application

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* 41. Balance your cheque book

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* 42. Do you have a child or children between the ages of 0-12 years? If yes, please answer the following questions. If no, please go to question 46.
I require regular childcare for my child/children

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* 43. I am able to find safe and affordable childcare for my child/children

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* 44. I use a licensed childcare provider, e.g. day care center

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* 45. I use a non-licensed childcare provider, e.g. in your or other’s home

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* 46. I attend Early Years and/or family or youth programs

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* 47. Does your family income allow you enough opportunity to engage in the activities that you wish to do together as a family?

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* 48. This question is for unpaid caregivers of young children or seniors or both. How well do you balance this role with the other demands in your life?

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* 49. Do you have enough time for yourself to maintain your health most of the time? (1 being no adequate time, being always adequate time)

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* 50. Please respond to these questions about your home.
Do you own your home?

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* 51. Do you feel your home is in good repair?

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* 52. Have you struggled to pay your bills in the past 6 months?

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* 53. Is your current home appropriate for your needs?

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* 54. Do you think that seniors in your community have adequate and affordable housing options as they

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* 55. Which one of the following categories would you say best describes your main activity?

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* 56. Do you have extended health benefits such as: dental, physiotherapy, etc.?

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* 57. This survey is about the factors that affect the wellbeing of people in our community. Are there other factors you would like to mention?

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* 58. Are you satisfied with customer service and communication at Langs? (Questions 56-64).
Courtesy of the person taking your call or greeting you at the reception desk

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* 59. Friendliness of the staff

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* 60. Amount of time waiting for appointment

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* 61. Comfort and safety while waiting

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* 62. Neat and clean building

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* 63. Knowing where to go within the building

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* 64. Adequate parking

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* 65. Langs website

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* 66. Information television screens at Langs

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* 67. Are you satisfied with programs and services at Langs? (Questions 65-71).
Accessibility of Langs programs or services

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* 68. Another agency or service located at Langs or North Dumfries

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* 69. Having access to a variety of services under one roof

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* 70. The program or service had impact on my health or well-being

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* 71. How well information about programs and services are communicated

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* 72. The variety of ways that people can volunteer at Langs

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* 73. My volunteer role (if applicable)

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* 74. Please rank your satisfaction with the following services at Langs if you have used them? (Questions 72-81).
Resource Centre

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* 75. Youth and Teen Services

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* 76. Early Years Services

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* 77. Adult/Older Adult Programs

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* 78. Diabetes Education Program

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* 79. Social Work Services

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* 80. Volunteer Services

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* 81. Primary Care Services (seeing your doctor or nurse practitioner)

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* 82. Agency Services onsite

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* 83. What is your age?

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* 84. What gender do you identify with?

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* 85. Are you?

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

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* 87. What is your total household income from all sources last year (optional)?

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* 88. How many people are in your household?

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