Community Perception Survey

Your community is part of Pathways to a Healthy Kansas, a Blue Cross and Blue Shield of Kansas initiative. The purpose of this survey is to gather your perceptions about opportunities for physical activity, healthy eating, and tobacco cessation in your community. The information gathered in this survey will inform our efforts in ensuring that community members have healthy options to choose from. This survey will be shared with the community once per year for each of the three years of the Pathways initiative.

Your responses will be compiled with other responses and will never directly identify your individual response. We are gathering some demographic information to ensure that we have gathered feedback from a broad representation of individuals in the community, but this will not be shared outside the project team. You can choose to skip questions that you don’t feel comfortable answering and you can stop at any time. We thank you for your participation! 

* 1. In which county do you currently reside:

* 2. If you live in Cheyenne County, which zip code do you live in?

* 3. In general, how would you rate the overall health of our community

* 4. Are you familiar with the U.S. recommendations for adult physical activity?

It is recommended that adults get at least 2 hours and 30 minutes each week of aerobic physical activity at a moderate level OR 1 hour and 15 minutes each week of aerobic physical activity at a vigorous level.  Adults should also do strength training activities, like push-ups, sit-ups and lifting weights, at least 2 days a week

* 5. Do you feel like you're meeting those recommendations?

* 6. Please rate your level of agreement with the following statements:

  Strongly Disagree Disagree Neutral Agree Strongly agree
My community has a sufficient number of sidewalks or bike/walk paths
My community has a sufficient number of parks/playgrounds
For walking at night, my community has adequate street lighting
In general, my community has sufficient opportunities for physical activity

* 7. Are you familiar with the U.S. recommendations for adult fruit and vegetable consumption?

It is recommended that adults eat 1 1/2 - 2 cups(3-4 servings) of fruit per day and 2-3 cups of vegetables (4-6 servings) of vegetables per day.

* 8. Do you feel like you're meeting those recommendations?

* 9. Please rate your level of agreement with the following statements

  Strongly disagree Disagree Neutral Agree Strongly agree
It is easy to find fresh fruits and vegetables in my community
The fresh produce in my community is of high quality
It is easy to find whole grain products, such as breads, cereals, pasta and snacks in my community
In general, my community has sufficient options for healthy eating

* 10. Are you aware of the efforts in your community to promote smoking cessation (i.e. quitting smoking)?

* 11. Please rate your level of support for raising the minimum age for tobacco purchases from the current age (18) to 21  years of age?

* 12. Please rate your level of support for policies that prohibit tobacco use (i.e. smoking and chewing tobacco) in the following settings:

  Definitely not supportive Not supportive Neutral Supportive Very Supportive
Local Parks
School grounds
Hospital grounds
Worksites

* 13. Were you aware of the Pathways to a Healthy Kansas Initiative that is being implemented by the Northwest Kansas Collaborative (Atwood, Bird City, Colby, St. Francis) in your community

* 14. Age?

* 15. Gender?

* 16. Ethnic group you most identify with?

* 17. Education

* 18. Where/how you got this survey:  (Check one)

T