Community Perceptions Survey

Your community is part of the Pathways to a Healthy Kansas, a Blue Cross Blue Shield initiative. The purpose of this survey is to gather your perceptions about opportunities for physical activity, healthy eating, and tobacco cessation in your community. The information gathered in this survey will inform our efforts in ensuring that community members have healthy options to choose from. Your responses will be compiled with other responses and will never directly identify your individual response. We are gathering some demographic informationĀ  to ensure that we have gathered feedback from a broad representation of individuals in the community, but this will not be shared outside the project team. You can choose to skip questions that you don't feel comfortable answering and you can stop at any time. We thank you for your participation.

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* 1. In general, how would you rate the overall health of our community?

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* 2. In general, my community has sufficient opportunities for physical activity.

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* 3. For walking at night, my community has adequate street lighting.

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* 4. In general, my community has sufficient options for healthy eating.

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* 5. Were you aware of the Pathways to a Healthy Kansas Initiative that is being implemented by Liberal Area Coalition for Families?

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* 6. Are you aware of efforts in your community to promote smoking cessation (i.e. quitting smoking)?

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* 7. Please rate your level of support for policies that prohibit tobacco use (i.e. smoking and chewing tobacco) in theĀ 
following settings.

  Definitely Not Supportive Not Supportive Neutral Supportive Very Supportive
Hospital Grounds
Clinics
Local Parks
Worksites
School Grounds

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* 8. Please rate this in order of greatest need in our community.

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* 9. Age:

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* 10. Gender:

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* 11. Ethnic Group:

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* 12. Education:

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* 13. Do you have a health concern of high importance we have not listed?

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* 14. What is the best way for us to communicate with you?

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