Community Needs Assessment Survey June 2019

Demographic Information

MHC Healthcare is conducting its 2019 Community Needs Assessment to determine how MHC can better serve you. Your input into this process is of great value to MHC, so we are requesting 10-15 minutes of your time to complete this Needs Assessment Survey. Your time is greatly appreciated!

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* 1. What is your ZIP code?

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* 2. About how long have you lived in the area?

Less than a year

1-2 years

3-5 years

6-10 years

11-20 years

More than 20 years

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* 3. What sex were you assigned at birth?

Male

Female

Choose not to disclose

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* 4. What is your current gender identity?

Male

Female

Transgender Male/Female-to-Male

Transgender Female/Male-to-Female

Other

Choose not to disclose

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* 5. What is your Sexual Orientation?

Straight (not Lesbian or Gay)

Lesbian or Gay

Bisexual

Something else

Do not know

Choose not to disclose

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* 6. Which of the following best represents your racial or ethnic heritage?

White

Black or African American

American Indian or Alaska Native

Non-Hispanic White or European American

Asian

Hispanic or Latino

Native Hawaiian and/or Other Pacific Islander

Other multiple race combinations greater than one percent (please specify)

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* 7. What is your marital status?

Single

Married

Married – Same sex

Widowed

Divorced

Separated

Living with partner

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* 8. What are the ages of the people who live in your household?

	Age
Yourself	Yourself Age menu
Person 2	Person 2 Age menu
Person 3	Person 3 Age menu
Person 4	Person 4 Age menu
Person 5	Person 5 Age menu
Person 6	Person 6 Age menu

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* 9. What is the predominant language spoken at home?

English

Spanish

Spanish and English

Other (please specify)

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* 10. Are you the primary caretaker for any child(ren)?

Yes

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* 11. Are you a Veteran?

Yes