2020 Baltimore Health Needs Survey Question Title * 1. What is your zip code? (Please write 5-digit Zip code) OK Question Title * 2. What is your gender? (Please check one) Male Female Transgender Don't Know Prefer Not to Answer Other (please specify) OK Question Title * 3. What is your age group? (Please check one) 18-29 years 30-39 years 40-49 years 50-64 years 65-74 years 75+ Don't Know Prefer Not to Answer OK Question Title * 4. Which one of the following is your race? (Please check all that apply) Black or African American White or Caucasian Asian Native Hawaiian or Other Pacific Islander American Indian or Alaska Native Don't Know Prefer Not to Answer Other /More than one race (please specify) OK Question Title * 5. Are you Hispanic or Latino/a? (Please check one) Yes No Don't Know Prefer Not to Answer OK Question Title * 6. Do you have health insurance? Yes No OK Question Title * 7. On how many days during the past 30 days was your mental health not good? (Mental health includes stress, depression, and problems with emotions) Zero Days Don't Know Prefer Not to Answer (Please specify how many days here) OK Question Title * 8. What are the three most important health problems that affect the health of your community? Please check only three. Alcohol/Drug Addiction Mental Health (Depression/Anxiety) Diabetes/High Blood Sugar HIV/AIDS Lung Disease/Asthma/COPD Smoking/Tobacco Use Sexually Transmitted Diseases Alzheimer's/Dementia Cancer Heart Disease/Blood Pressure Infant Death Stroke Overweight/Obesity Don't Know or Prefer Not to Answer Other (please specify) OK Question Title * 9. What are the three most important social/environmental problems that affect the health of your community? Please check only three. Availability/Access to Doctor's Office Availability/Access to Insurance Domestic Violence Limited Access to Healthy Foods School Dropout/Poor Schools Lack of Job Opportunities Race/Ethnicity Discrimination Social Isolation/Loneliness Child Abuse/Neglect Lack of Affordable Child Care Housing/Homelessness Neighborhood Safety/Violence Poverty Limited Places to Exercise Transportation Problems Don't Know or Prefer Not to Answer Other (please specify) OK Question Title * 10. What are the three most important reasons people in your community do not get health care? Please check only three. Cost - Too Expensive/Can't Pay No Insurance Lack of Transportation Language Barrier Worried about Immigration Status Fear or Mistrust of Doctors Wait is Too Long No Doctor Nearby Insurance Not Accepted Cultural/Religious Beliefs Child Care Wait is Too Long Don't Know or Prefer Not to Answer Other (please specify) OK Question Title * 11. Which of the following apply to you? I have been diagnosed with the Coronavirus (COVID-19) A household member has been diagnosed with the Coronavirus A family member outside my household has been diagnosed with the Coronavirus A friend or someone I know outside my family has been diagnosed with the Coronavirus I don't know anyone personally who has been diagnosed with the Coronavirus Prefer not to say OK Question Title * 12. As a result of COVID-19, have you needed any of the following? (Check all that apply) Financial Assistance Food Assistance Rental Assistance Translation/Interpretation Services Energy Assistance WiFi/Internet Assistance Housing/Shelter Child Care None Other (please specify) OK Question Title * 13. When it comes to COVID-19, what are you most concerned about right now? (Rank the following options in order of importance. 1 = Most important to 4 = Least important) 1 2 3 4 Members of my household becoming infected 1 2 3 4 The health of my community as the pandemic continues 1 2 3 4 The emotional health of my household 1 2 3 4 Financial hardship OK Question Title * 14. What ideas or suggestions do you have to improve the health in your community? OK THANK YOU FOR COMPLETING THE SURVEY!