Alcona Health Center
Community Health Needs Assessment
Survey Questionnaire 2021

Alcona Health Center (AHC) is surveying service area residents and patients to better understand the needs of the local community. This survey can be completed by anyone 18 years or older. Your responses are completely anonymous. We estimate this survey will take about 10 minutes. We hope you will take the time to complete this survey. Your opinion is valuable and will help AHC provide better services to those who need them. Thank you for your help!

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* 1. In which county do you reside?

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* 2. What zip code do you live in?

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* 3. Have you ever received services at AHC?

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* 4. If yes, what services (select all that apply):

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* 5. Of the other services you receive at AHC, how satisfied are you with the care you have received?

  Not at All Slightly Satisfied Moderately Satisfied Very Satisfied Extremely Satisfied Never Received this Service at AHC - N/A
Primary Medical Care
Behavioral Health
Substance Use Disorder
Dental/Oral Health
HIV
Acute Medical Care
Pharmacy

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* 6. Do you think of yourself as (sexual orientation):

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* 7. Do you think of yourself as (gender identity):

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* 8. What sex was originally listed on your birth certificate?

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* 9. Please select your age group:

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* 10. What do you consider to be your primary racial group?

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* 11. Are you of Hispanic, Latino, or Spanish origin, such as Mexican, Puerto Rican, or Cuban?

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* 12. How many adults (age 18 or older), including yourself, live in your household?

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* 13. How many adults 65 years of age or older, including yourself, live in your household?

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* 14. How many children in the following age groups live in your household?

  0 1 2 3 4 5 or more
Ages 0-4yrs
Ages 5-17yrs

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* 15. What is the highest level of education you have completed?

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* 16. What is your marital status? (select one)

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* 17. Counting income from all sources (including all earnings from jobs, unemployment insurance, pensions, public assistance, etc.) and counting income from everyone living in your home, which of the following ranges did your household income fall into last year?

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* 18. What is your current employment status? (check all that apply)

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* 19. Do you have a primary care physician, physician assistant, nurse practitioner, or health clinic?

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* 20. If yes, have you been seen for a physical exam in the past year?

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* 21. What is your usual method of transportation to get to health appointments?

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* 22. What is the best way to inform people about new health services available in your area?

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* 23. What is the most you could afford to pay to visit a primary care / dental / mental health provider?

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* 24. Everyone experiences certain needs which are essential for their daily living. Rate you important each need is to you at the present time:

  Not Important A Little Important Somewhat Important Very Important Extremely Important
Finding Affordable Permanent Housing
Getting Free Meals
Short-term Shelter (less than 90 days)
Temporary Housing with Support Services (also called “Transitional Housing”)
Job Placement
Job Training
Getting Public Benefits (e.g. AFDC, SSI, Welfare)
Assistance with Budgeting Money
Getting Transportation
Parenting Training
Available Child Care
Individual Counseling
Family Counseling
Drug or Alcohol Treatment
Case Management
Mental Health Care
Trauma – Childhood abuse/neglect, sexual assault, gun violence, prison, etc.
Life Skills Training (e.g. learning health habitats, time management, cooking, etc.)
Furthering Your Education
Medical Services
Dental Services
Obtaining Legal Assistance
Being Involved in Support Groups
Having Information on Agency Services
Health Care Information
OB/GYN
Eye Doctor (e.g. vision services)

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* 25. Rate how easy or difficult it is for you to access the below resources to meet your need. If you do not need a certain service, please select N/A (Not a Need).

  Always Difficult Sometimes Difficult Sometimes Easy Always Easy N/A - Not a Need
Finding Affordable Permanent Housing
Getting Free Meals
Short-term Shelter (less than 90 days)
Temporary Housing with Support Services (also called “Transitional Housing”)
Job Placement
Job Training
Getting Public Benefits (e.g. AFDC, SSI, Welfare)
Assistance with Budgeting Money
Getting Transportation
Parenting Training
Available Child Care
Individual Counseling
Family Counseling
Drug or Alcohol Treatment
Case Management
Mental Health Care
Trauma – Childhood abuse/neglect, sexual assault, gun violence, prison, etc.
Life Skills Training (e.g. learning health habitats, time management, cooking, etc.)
Furthering Your Education
Getting Assistance in Increasing English Fluency
Medical Services
Dental Services
Obtaining Legal Assistance
Being Involved in Support Groups
Having Information on Agency Services
Health Care Information
Improving Physical Safety (e.g. more police on streets, safer shelters, etc.)
OB/GYN
Eye Doctor (e.g. vision services)

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* 26. AHC wants to thank you for your participation! We will be using your responses to improve the services that we provide to our community. If you have any additional comments, please write them below. 

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