* 1. What county do you live in?

* 2. What is your zip code?

* 3. Age:

* 4. Gender:

* 5. Race:

* 6. I am Hispanic/ Latino.

* 7. My job status is:

* 8. My household income (in $) is:

* 9. Highest level of education:

* 10. I have this type of health care coverage:

* 11. I have been diagnosed by a doctor, nurse, or other health care provider with the following: (Check all that apply)

* 12. My main form of transportation is:

* 13. I think these are the 3 main reasons why people in our community do not seek health care:

* 14. I think these are the 3 main reasons that prevent people from being physically active in our community:

* 15. I think these are the 3 main reasons that prevent people in our community from eating healthy foods:

* 16. I think these are the 3 most important health concerns in our community:

* 17. I think these are the 3 most important factors for a healthy community:

* 18. I would rate the overall health of our community as:

* 19. I use the following tobacco products (Check all that apply).

* 20. I am exposed to secondhand smoke:

* 21. If you are exposed to secondhand smoke, where are you exposed? (Check all that apply).

* 22. Thinking about the last 30 days, not including juices, how often did you eat fruit?

* 23. Thinking about the last 30 days, not including juices, how often did you eat vegetables?

* 24. In the last week, how many times were you physically active?

* 25. How much time do you spend doing physical activity on a typical day?

* 26. How important is it to exercise regularly?

* 27. When I cook at home, I am most likely to prepare my food by:

* 28. How important is it to eat fruits and vegetables regularly?

* 29. What makes you love your community?

* 30. FOR SURVEY STAFF USE ONLY: Paper or Electronic?

* 31. FOR SURVEY STAFF USE ONLY: ID#

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