Madison County Health and Food Access Survey Question Title * 1. What zip code or city do you live in? Question Title * 2. In a typical week, what kind(s) of transportation does your household use? (Mark all that apply) Public Transportation Own vehicle Walk Bike Other (please specify) Question Title * 3. Do you or others in your household have a valid driver's license? Yes No If yes, how many others? Question Title * 4. How often do you rely on or use public transportation? Daily Weekly Monthly Seldom Never Question Title * 5. What transportation services do you use? Rides from friends/relatives HIRTA Taxi service Other (please specify) Question Title * 6. For what purposes do you use public transportation? (Mark all that apply) Medical appointments Employment Education Personal needs Groceries Food Pantry I don't use it Other (please specify) Question Title * 7. What issues if any, prevent you from using public transportation? (Mark all that apply) I don't know how to use it I didn't know it was available in my area I can't afford to use it It doesn't go to the destinations that I need It is inconvenient Other (please specify) Question Title * 8. What times do or would you need public transportation services available to you? (Mark all that apply) Early morning (5am-10am) Mid-day (10am-4pm) Evening (4pm-9pm) Late night (9pm-5am) None Question Title * 9. Which of the following services would you use if they were available in your area? (Mark all that apply) Bus stop Call ahead for ride (curb-to-curb)(passenger service that picks up and drops off passengers at curbside) Call ahead for ride (door-to-door)(passenger service provided to entryway of pick-up and drop-off addresses by a driver or transportation escort) Carpool list/group How often would you use this service? Question Title * 10. In the past 6 months, did you miss specific trips or could not make trips due to lack of transportation? (Mark all that apply) School Social service appointment Kids' activities Medical appointment Religious event Social event Shopping Visiting family/friends Groceries Food Pantry Employment Didn't miss any Senior nutrition/activity center Other (please specify) Question Title * 11. How often do you buy food? Everyday Twice per week Once per week Twice per month Hardly ever Question Title * 12. In the past 6 months, have you had to skip or lower the portion size of a meal due to low availability of food? Yes No If yes, how often? Question Title * 13. In the past 6 month, have you ever felt forced to restrict spending on other necessities (personal products, bills, medication) in order to afford food? Yes No Question Title * 14. Is there a certain time of the month when you are more stressed about food than usual? No, I am never stressed about food No, I am always stressed about food Yes, the beginning of the month Yes, the middle of the month Yes, the end of the month Question Title * 15. Where do you and your household members typically get food? (Mark all that apply) Grocery store Fast food/restaurants Farmer's market Food pantry Church/organization Home garden Meal site Community garden Home-delivered meals School Friend/relative house Convenience store Other (please specify) Question Title * 16. How long does it take you to get to your usual food source? 0-5 minutes 5-10 minutes 10-20 minutes 20-30 miniutes More than 30 minutes Question Title * 17. How would you rate the quality of food from your main food provider? (1=worst, 5=best) 1 2 3 4 5 Fruit Fruit 1 Fruit 2 Fruit 3 Fruit 4 Fruit 5 Vegetables Vegetables 1 Vegetables 2 Vegetables 3 Vegetables 4 Vegetables 5 Breads Breads 1 Breads 2 Breads 3 Breads 4 Breads 5 Meats/Proteins Meats/Proteins 1 Meats/Proteins 2 Meats/Proteins 3 Meats/Proteins 4 Meats/Proteins 5 Dairy Dairy 1 Dairy 2 Dairy 3 Dairy 4 Dairy 5 Question Title * 18. Are certain foods difficult to get in your neighborhood? Yes No If yes, which foods? Question Title * 19. For you, what is the main obstacle in getting the food you need? Cost of food Time for shopping Dietary restrictions Safety Quality of food available Distance to store/transportation Other (please specify) Question Title * 20. What would you like to see change in your neighborhood's food system? (Mark all that apply) Grocery store closer to me More farmer's markets Access to free garden space Gardening workshops Nutrition classes More fresh and perishable* food available where I get food (*bread, milk, eggs) Classes on cooking, canning, and preserving food More emergency food locations Meal planning and budgeting classes Other (please specify) Question Title * 21. Which of the following would you use if available? (Mark all that apply) Grocery delivery to nearby location (online or phone order) Grocery delivery to your house (online or phone order) Carpool group to grocery store or food pantry Emergency food delivery to your house Question Title * 22. Please leave additional comments below. Done