Your responses to this optional survey are anonymous and will inform how hospitals and agencies work to improve health in our community. Thank you!

 Instructions: You must be 18 years or older to complete this survey. Please answer all questions and return the survey as indicated. Please answer all questions and return the survey as indicated. For questions about this survey, contact community@southerncoos.org.

Question Title

* 1. What is your ZIP code? Please enter the 5-digit ZIP code.

Question Title

* 2. What city do you live in? Please check one.

Question Title

* 3. What is your gender? Please check one.

Question Title

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

Question Title

* 5. Which of the following is your race? Please check one.

Question Title

* 6. Are you Hispanic or Latino/a? Please check one.

T