Charles River Community Health - Community Needs Survey Section A: Demographics/Background Question Title * 1. Are you a patient at Charles River Community Health? Yes No Question Title * 2. What is your ZIP Code? Question Title * 3. How old are you? 18-24 25-34 35-44 45-54 55-64 65+ Question Title * 4. Do you describe yourself as a man, awoman, or in some other way? Man Woman Some other way Question Title * 5. Do you consider yourself to be: Heterosexual or straight (attraction to the opposite gender of yourself) Gay or lesbian (attraction to the same gender as yourself) Bisexual (attraction to all genders) Other Choose not to answer Not sure Question Title * 6. Do you identify as Hispanic or Latinx? Yes No Question Title * 7. Which of the following would you say is your race? Check all that apply. White Black or African American Native Hawaiian or other Pacific Islander American Indian or Alaska Native Hispanic or Latino Asian or Asian American Two or more races Other (please specify) Question Title * 8. What is your primary language spoken? English Spanish Chinese Portuguese Russian Vietnamese Haitian Creole Arabic Cape Verdean Thai Other (please specify) Question Title * 9. What is the highest grade or year of school that you have completed? Check one. Never attended school or only attended Kindergarten All or Some Elementary (grades 1 - 8) Some High School (grades 9 - 12) High school Graduate or G.E.D Some College College degree or higher Question Title * 10. Check the one answer that best describes your current employment status: Employed (Full Time) Employed (Part Time) Unemployed Homemaker Student Retired Unable to work Question Title * 11. How many children (younger than 18) live in your household? Question Title * 12. How many members of your household, including yourself, are 18 years or older? Question Title * 13. What is the total annual household income earned by all individuals in your household? Check one: $0 - $12,879 $12,880 - $19,318 $19,319-$22,538 $22,539- $25,758 $25,759- $32,197 $32,198-$38,637 Over $38,637 Question Title * 14. Do you have a smart phone? Yes No Question Title * 15. Do you have a computer or other device to connect to internet? Yes No Question Title * 16. Do you currently have access to theinternet? Yes No Next