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* 1. What is your zip code? (Please write 5-digit Zip code)

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* 2. What is your gender? (Please check one)

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* 3. What is your age group?  (Please check one)

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* 4. Which one of the following is your race? (Please check all that apply)

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* 5. Are you Hispanic or Latino/a? (Please check one)

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* 6. Do you have health insurance?

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* 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)

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* 8. What are the three most important health problems that affect the health of your community?  Please check only three.

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* 9. What are the three most important social/environmental problems that affect the health of your community?  Please check only three.

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* 10. What are the three most important reasons people in your community do not get health care?  Please check only three.

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* 11. Which of the following apply to you?

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* 12. As a result of COVID-19, have you needed any of the following? (Check all that apply)

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* 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)

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* 14. What ideas or suggestions do you have to improve the health in your community?

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