This survey is for anyone who lives or works in Worth County and will take about 6 minutes to complete. It is designed to help our health department understand community needs and gaps in service. Your input will allow us to direct our services to fill these gaps.

Please answer all the survey questions to the best of your ability. Information is kept confidential. Thank you for taking the time to help us make this community a happier, healthier place to live.

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* 1. Do you live and/or work in Worth County?

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* 2. Which Worth County zip code do you live and/or work in?

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* 3. On a scale of 1 to 5, how would you rate your community as a safe place to live and/or raise children?

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* 4. From the following list, please rank all eight choices in order from most to least important to you, with 1 being the most important to you and 8 being the least important to you.

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* 5. From the following list, please choose three topics you would like health education on in Worth County.

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* 6. Overall, how would you rate your physical health?

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* 7. Is an exercise space easily accessible to you?

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* 8. How many days per week do you engage in moderate to vigorous exercise for at least 30 minutes each day?

Moderate/vigorous exercise examples: brisk walking, manual labor, farming, swimming, sports, weightlifting, yoga, etc.

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* 9. On a typical day, how many servings of fruits and/or vegetables do you consume?

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* 10. Do you have access to fresh fruits and vegetables within 10 miles of where you live?

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* 11. Overall, how would you rate your mental health?

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* 12. If needed, are mental/behavioral health services easily accessible to you regarding how quickly you can be seen, the location, the cost, etc.?

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* 13. How many days per week do you consume tobacco/smoking/vaping products?

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* 14. How many days per week do you consume alcohol?

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* 15. If you have not received a flu vaccination this year, what has prevented you from getting it? (Check all that apply).

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* 16. How far do you travel to get to your primary care provider?

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* 17. If you needed emergency medical attention, would you feel confident in being able to receive care in a timely manner?

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* 18. Where do you obtain most of your medical/public health information?

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* 19. What type of health insurance do you have?

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* 20. Within the past year, were you able to receive needed healthcare?

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* 21. Please respond to the following statement: 

There are adequate housing options in Worth County.

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* 22. Please respond to the following statement: 

There are adequate employment opportunities in Worth County.

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* 23. Please respond to the following statement: 

There are adequate high-quality childcare options in Worth County.

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* 24. Please respond to the following statement: 

There are adequate transportation options in Worth County to meet my daily needs.

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* 25. What is your gender identity?

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* 26. What age range do you fall under?

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* 27. What is your race?

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* 28. What is your highest level of education?

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* 29. What is your annual household income?

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* 30. How did you hear about this survey?

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* 31. Please share any additional health priorities and/or comments you may have.

This project is supported by the Centers for Disease Control and Prevention of the U.S. Department of Health and Human Services (HHS) as part of a financial assistance award totaling $35,569,951 with 100 percent funded by CDC/HHS. The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement, by CDC/HHS, or the U.S. Government.

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