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* 1. Please take a moment to complete the following survey - it should take less than 10 minutes to complete. The purpose of this survey is to get your input about community health concerns in your county. This survey will be used to help guide the Community Health Needs Assessment taking place in your county. The community partners will use the results of this survey, along with other information, to identify the most pressing health issues which can be addressed through community action. Your responses will not be associated with you in any way. If you have previously completed this survey, please disregard. Remember, your opinion is important to us!
Thank you for your time and please contact us if you have any questions concerning this survey or need help completing it, please contact Emily Sarkees (edillama@hsc.wvu.edu)


Are you a resident of Monongalia County?

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* 2. Below is a list of public high schools in Monongalia County. Please choose the one that is closest to where you reside.

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* 3. In your opinion, what is the most important health problem or health issue for residents of your County?

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* 4. Thinking about your county overall, what helps keep residents healthy?

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* 5. Thinking specifically about your own experience, what local places, programs, or organizations have helped you or someone close to you focused on personal well-being?

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* 6. How would you rate your County as a "Healthy Community"?

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* 7. In the following list, what do you think are the 3 most important "health problems" or "health issues" in your County? Please choose ONLY 3.

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* 8. Please indicate your level of agreement with each of the following statements about the quality of life in your County:

  Strongly Disagree Disagree Agree Strongly Agree I don't know/Not applicable
I am satisfied with the quality of life in my County.
All residents believe that they, individually or collectively, can make your County a better place to live.
There is sufficient, safe, and affordable housing in my County.
There are jobs available in my County.
There is quality childcare available in my county.
My County is a safe place to live.
Neighbors know and trust one another and look out for one another.
There are support networks for individuals and families (neighbors, support groups, faith community, outreach, agencies, and organizations) during times of stress and need.
My County is a good place to raise children.
The public education system in my County adequately meets the physical health needs of our children. (e.g. school food, physical education/PE, etc.)
The public education system in my County adequately meets the health education needs of our children. (e.g. hygiene and personal care, pregnancy and STI prevention, etc.)
There are an adequate number of safe places for children to play and exercise in my County.
My County has adequate and safe access to recreation and exercise opportunities for adults.
My County has adequate access to affordable healthy foods.
My County has adequate health and wellness activities.
My County is a safe place to walk and bike.
My County has sufficient public transportation.
There are adequate sidewalks in my County.

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* 9. Please indicate your level of agreement with each of the following statements about access to healthcare and medical needs in your County:

  Strongly Disagree Disagree Agree Strongly Agree I don't know/Not applicable
I have easy access to the medical specialists I need.
I am very satisfied with the medical care I receive.
I have access to adequate healthcare.
Sometimes it is a problem for me to cover my share of the cost for a medical care visit.
Sometimes it is a problem for me to cover my share of the cost of medication.
I am able to get medical care whenever I need it.

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* 10. In your opinion, from the following list, what do you think are the most important "risky behaviors" in your County? Risky behaviors have the greatest impact on the overall health of the community. You may select more than one.

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* 11. What is your gender?

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* 12. What is your age range?

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* 13. What is your marital status?

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* 14. How many children under the age of 18 live in your household?

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* 15. Do you care for a live-in elderly adult in your household?

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* 16. Are you of Hispanic or Latino origin or descent?

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* 17. Which of these groups would you say best describes your race?

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* 18. What is your approximate average household income?

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

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* 20. Do you see a healthcare provider on a regular basis for physicals, screenings, or other preventative medicine?

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* 21. How do you pay for healthcare? Please select all that apply.

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* 22. Have you ever been told by a doctor, nurse or other health professional that you have high blood pressure?

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* 23. Have you ever been told by a doctor, nurse, or other health professional that your blood cholesterol is high?

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* 24. Have you ever been told by a doctor that you have diabetes ("sugar")?

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* 25.  How many days a week do you eat vegetables? (Enter 0-7)

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* 26. Not counting juice, how many days a week do you eat fruit? (Enter 0-7)

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* 27. How many days a week do you consume soda or other processed, sugary foods? (Enter 0-7)

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* 28. How many days a week do you get at least 30 minutes of moderate physical activity such as brisk walking, bicycling, gardening or anything else that causes some increase in breathing and heart rate? (Enter 0-7)

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* 29. Do you smoke cigarettes every day, some days, or not at all?

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* 30. Have you smoked at least 100 cigarettes in your entire life?

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* 31. About how tall are you (in feet and inches)?

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* 32. About how much do you weigh (in pounds)?

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