Community Health Survey Question Title * 1. What is the one thing that you would do to improve the health of local residents? Question Title * 2. Do any of the following prevent you from living a healthy lifestyle? Unsafe neighborhoods Limited access to fresh fruits and vegetables Unavailable transportation Health insurance coverage Lack of motivation Lack of knowledge Limited access to exercise opportunities Limited access to services Unhealthy personal habits Unemployment Other (please specify): Question Title * 3. Through demographic and health characteristic analysis, the following have been identified as possible priorities for the area. Please select 3 areas that you feel are the top priorities for Clinton County. In writing 1, 2, and 3 next to the selected areas, please only use each number once. Question Title * 4. Where would be the best place for you to receive health and wellness information and communications? Community Programs Computer Programs and Video Learning Self-Paced Employer Health Programs Faith-Based Organization (Church) Local radio station Newspaper Organization where you volunteer Social Networks (i.e. Facebook, etc.) Through Civic Organizations or Clubs 1- Least Desired Place 1- Least Desired Place Community Programs 1- Least Desired Place Computer Programs and Video Learning Self-Paced 1- Least Desired Place Employer Health Programs 1- Least Desired Place Faith-Based Organization (Church) 1- Least Desired Place Local radio station 1- Least Desired Place Newspaper 1- Least Desired Place Organization where you volunteer 1- Least Desired Place Social Networks (i.e. Facebook, etc.) 1- Least Desired Place Through Civic Organizations or Clubs 2 2 Community Programs 2 Computer Programs and Video Learning Self-Paced 2 Employer Health Programs 2 Faith-Based Organization (Church) 2 Local radio station 2 Newspaper 2 Organization where you volunteer 2 Social Networks (i.e. Facebook, etc.) 2 Through Civic Organizations or Clubs 3 3 Community Programs 3 Computer Programs and Video Learning Self-Paced 3 Employer Health Programs 3 Faith-Based Organization (Church) 3 Local radio station 3 Newspaper 3 Organization where you volunteer 3 Social Networks (i.e. Facebook, etc.) 3 Through Civic Organizations or Clubs 4 4 Community Programs 4 Computer Programs and Video Learning Self-Paced 4 Employer Health Programs 4 Faith-Based Organization (Church) 4 Local radio station 4 Newspaper 4 Organization where you volunteer 4 Social Networks (i.e. Facebook, etc.) 4 Through Civic Organizations or Clubs 5- Most Desired Place 5- Most Desired Place Community Programs 5- Most Desired Place Computer Programs and Video Learning Self-Paced 5- Most Desired Place Employer Health Programs 5- Most Desired Place Faith-Based Organization (Church) 5- Most Desired Place Local radio station 5- Most Desired Place Newspaper 5- Most Desired Place Organization where you volunteer 5- Most Desired Place Social Networks (i.e. Facebook, etc.) 5- Most Desired Place Through Civic Organizations or Clubs Please list other methods: Question Title * 5. Are there any other health needs that we should consider as a priority in the region? Yes No If yes, please describe: General Information- For Analysis Purposes Only This information will not be used to identify you as a participant. The information is important to ensure that we have data that represents all members of the community. Question Title * 6. What is your household zip code? Question Title * 7. Please identify your gender: Male Female Prefer not to say Other (please specify): Question Title * 8. What year were you born (4-digit year)? Question Title * 9. Are you Hispanic/Latino? Yes No Question Title * 10. What is your race? American Indian or Alaska Native Asian or Asian American Black or African American Hispanic or Latino Middle Eastern or North African Native Hawaiian or other Pacific Islander Another race White Other (please specify): Question Title * 11. Highest level of education you have completed: Less than high school High school diploma or equivalent Trade or technical school beyond high school Some college 4- year college degree More than 4- year degree Question Title * 12. What is your disability status? Do not have a disability. Have a disability. Question Title * 13. What is your approximate household annual earned income before taxes? Less than $20,000 $20,000- $40,000 $40,001- $60,000 $60, 001- $80,000 $80,001- $100,000 More than $100,000 Retired Prefer not to say Next