UMI Community Imaging Clinic Social Needs Screening Survey

As a free nonprofit clinic, UMI Community Imaging Clinic is committed to serving its community and to contribute to larger research for the purpose of advancing care and services for the disadvantaged members of our society.

We thank you for completing this anonymous survey that helps us better identify the needs of communities we serve.

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* 1. HOUSING: Are you worried or concerned that in the next two months you may not have stable housing that you own, rent, or stay in as a part of a household?

Yes

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* 2. HOUSING: Think about the place you live. Do you have problems with any of the following? (check all that apply)

Bug infestation

Mold

Lead paint or pipes

Inadequate heat

Oven or stove not working

No or not working smoke detectors

Water leaks

None of the above

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* 3. FOOD

	Often true	Sometimes true	Never true
Within the past 12 months, you worried that your food would run out before you got money to buy more.	Within the past 12 months, you worried that your food would run out before you got money to buy more. Often true	Within the past 12 months, you worried that your food would run out before you got money to buy more. Sometimes true	Within the past 12 months, you worried that your food would run out before you got money to buy more. Never true
Within the past 12 months, the food you bought just didn’t last and you didn’t have money to get more.	Within the past 12 months, the food you bought just didn’t last and you didn’t have money to get more. Often true	Within the past 12 months, the food you bought just didn’t last and you didn’t have money to get more. Sometimes true	Within the past 12 months, the food you bought just didn’t last and you didn’t have money to get more. Never true

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* 4. TRANSPORTATION: Do you put off or neglect going to the doctor because of distance or transportation?

Yes

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* 5. UTILITY" In the past 12 months has the electric, gas, oil, or water company threatened to shut off services in your home?

Yes

Already shut off

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* 6. CHILDCARE: Do problems getting child care make it difficult for you to work or study?

Yes

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* 7. EMPLOYMENT: Do you have a job?

Yes

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* 8. EDUCATION: Do you have a high school degree?

Yes

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* 9. FINANCES: How often does this describe you? I don’t have enough money to pay my bills:

Never

Rarely

Sometimes

Often

Always

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* 10. PERSONAL SAFETY

	Never	Rarely	Sometime	Fairly often	Frequently
How often does anyone, including family, physically hurt you?	How often does anyone, including family, physically hurt you? Never	How often does anyone, including family, physically hurt you? Rarely	How often does anyone, including family, physically hurt you? Sometime	How often does anyone, including family, physically hurt you? Fairly often	How often does anyone, including family, physically hurt you? Frequently
How often does anyone, including family, insult or talk down to you?	How often does anyone, including family, insult or talk down to you? Never	How often does anyone, including family, insult or talk down to you? Rarely	How often does anyone, including family, insult or talk down to you? Sometime	How often does anyone, including family, insult or talk down to you? Fairly often	How often does anyone, including family, insult or talk down to you? Frequently
How often does anyone, including family, threaten you with harm?	How often does anyone, including family, threaten you with harm? Never	How often does anyone, including family, threaten you with harm? Rarely	How often does anyone, including family, threaten you with harm? Sometime	How often does anyone, including family, threaten you with harm? Fairly often	How often does anyone, including family, threaten you with harm? Frequently
How often does anyone, including family, scream or curse at you?	How often does anyone, including family, scream or curse at you? Never	How often does anyone, including family, scream or curse at you? Rarely	How often does anyone, including family, scream or curse at you? Sometime	How often does anyone, including family, scream or curse at you? Fairly often	How often does anyone, including family, scream or curse at you? Frequently