Dear Community Member:
Please read the information below before beginning the questionnaire.
Purpose: The purpose of the community health needs assessment (CHNA) is to evaluate the health-related needs in the communities MidMichigan Health serves and use this information to fulfill our mission. This questionnaire is part of the CHNA. The questionnaire seeks to understand the strengths and areas in need of support in our communities. To participate in this questionnaire, you must be 18 years of age and older during the time the questionnaire is self-administered. You will be asked to supply your age, race/ethnicity, household income, level of education, gender identity, zip code, and other applicable demographic information. Additionally, you will be asked to provide your opinion on the strengths and areas of need in your community.
Funding: This CHNA is unfunded.
Study Procedure: Participation in this CHNA involves completing an online questionnaire. It should take between 5-7 minutes to complete the questionnaire.
Risks: The primary risk of participation in this CHNA is a potential loss of confidentiality. Some of the questionnaire questions are personal in nature and may make you feel uncomfortable. You do not have to answer any questions that make you uncomfortable or that you do not want to answer.
Benefits: You will not directly benefit from participating in this CHNA.
Confidentiality: We will keep your information confidential by not collecting/asking for any identifiable data. Your information will be stored in a password-protected computer file. We will not share your information with other researchers outside of MidMichigan Health. If we share your information, we will remove any and all identifiable information so that you cannot reasonably be identified.
The study will be used by MidMichigan Health to fulfill partial requirements to maintain our tax-exempt status under section 501(c)(3) of Federal Internal Revenue Code. The results of this CHNA may be published or to support community health improvement initiatives. Identifiable information will not be used for these purposes.
Compensation: You will not be given any form of compensation for participating in this CHNA.
Contact Information: If you have any questions about the CHNA, you can contact MidMichigan Medical Center-Alpena Community Health Coordinator Erica Phillips at erica.phillips@midmichigan.org or by phone at 989-356-7753.
Voluntary Participation: Participation in the CHNA is your choice. You may refuse to participate anytime, even after signing this form, with no penalty or loss of benefits to which you are otherwise entitled. You may choose to leave the CHNA at any time with no loss of benefits to which you are otherwise entitled. If you leave the CHNA, the information you provided will be kept confidential. You may request, in writing, that your identifiable information be destroyed. However, we cannot destroy any information that has already been published.
Statement of Consent: I have read this form. I have had an opportunity to ask questions and am satisfied with the answers I received. I click "NEXT" below to indicate my consent to participate in this CHNA.
