Menard County 2021 Community Health Needs Assessment Survey

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* 1. Please mark all categories that apply: GENDER

Female

Male

Other

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* 2. Please mark all categories that apply: RACE

White

Black/ African American

Asian/Pacific Islander

Native American/Indigenous

Other

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* 3. Please mark the category that applies: ETHNICITY

Hispanic/Latino(a)

Non-Hispanic/Latino(a)

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* 4. Please mark the category that applies: AGE

Under 18

18-24

25-34

35-44

45-54

55-64

65+

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* 5. Please mark the category that applies: EDUCATION

Some High School

High School Diploma/GED

Some College/Trade or Technical School

Associates' Degree

Bachelor's Degree

Advanced Degree

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* 6. What is your zip code?

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* 7. Do you have a disability?

Yes, I have a disability.

No, I do not have a disability.

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* 8. How would you rate the overall health of Menard County?

Very Healthy

Healthy

Fairly Healthy

Not Very Healthy

Unhealthy

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* 9. What is the ONE thing you think should be done to improve the health of Menard County?

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* 10. Please select the top 3 most serious health issues in Menard County from the following options.

Chronic Respiratory Disease (e.g. asthma, COPD)

Access to Healthcare

Mental Health

Cancer

Substance Abuse