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* 1. In what zip code is your home located? (enter your 5-digit zip code)

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* 2. What is your gender?

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* 3. Which race/ethnicity best describes you? (Please choose only one.)

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* 4. Which category below includes your age?

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* 5. Which category below includes your household income?

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* 6. The community has adequate health and wellness activities.

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* 7. The community has adequate meeting spaces for groups, clubs, and large events.

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* 8. I am satisfied with the number of cultural events in my community. (Tribal events, music, plays, art shows, etc.)

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* 9. I am satisfied with the health care system in our community.

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* 10. I have easy access to the medical specialists I need.

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* 11. I am very satisfied with the medical care I receive.

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* 12. Sometimes it is a problem for me to cover my share of the cost for a medical care visit.

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* 13. How do you pay for your health care?

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* 14. I am able to get medical care whenever I need it.

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* 15. This community is a good place to raise children.

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* 16. There are adequate parenting programs available in my community.

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* 17. I have access to quality and affordable child care.

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* 18. I am satisfied with my local school district preparing students for success in the future.

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* 19. There are adequate after school programs for elementary age children to attend.

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* 20. There are adequate after school opportunities for middle school and high school age students.

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* 21. There are plenty of recreation opportunities for children in my community.

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* 22. There are plenty of non-sports-related activities for children in my community.

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* 23. This community is a good place to grow old.

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* 24. There are networks of support for the elderly living alone. (transportation, grocery shopping, meals on wheels, social support)

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* 25. There is a public transportation service that takes residents to medical facility, shopping or to work.

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* 26. Food assistance programs are available and easy to access within our community.

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* 27. I have access to fresh fruits and vegetables.

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* 28. I have access to affordable housing.

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* 29. There are adequate jobs available in the community.

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* 30. There are opportunities for advancement in the jobs that are available in the community.

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* 31. The community is a safe place to live. (considering residents' perception of safety in the home, workplace, schools, playgrounds, parks, shopping areas)

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* 32. Neighbors know and trust one another and look out for one another.

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* 33. There are support networks for individuals and families (neighbors, support groups, faith community, outreach agencies, and organizations) during times of stress and need.

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* 34. Healthcare referral and resource information is easy to access.

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* 35. Behavioral/mental health services are available and easy to access within our community.

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* 36. In the following list, what do you think are the five most critical health problems in our community?  Check only 5.

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* 37. In the following list, what do you think are the five most common risky behaviors in our community? Check only 5.

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* 38. What do you think are the five most critical behavioral health concerns in your community? Check only 5.

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* 39. Please share any comments or suggestions about how to make your community happier or healthier.

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* 40. Do you have internet access or WIFI in your home?

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* 41. What device(s) do you use in your home when accessing the internet?

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