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Community Themes and Strengths Assessment Survey
1.
Is there a place within your community where you can buy healthy foods, such as fresh produce?
Yes
No
I don't know
2.
How accessible are areas to be physically active in your community?
Not accessible
Somewhat accessible
Moderately accessible
Very accessible
3.
Do you think that there are enough safe places for children to play within your community?
Yes
No
I don't know
4.
What do you feel is the biggest health problem in your community? (Select top 3)
Poor health behaviors (Smoking, poor diet, limited exercise)
Economic challenges (unemployment, poverty, education levels)
Limited access to health care
Drug and/or alcohol abuse
Health of babies, mothers, and children (teen pregnancy, childhood obesity, prenatal care)
Chronic illness (diabetes, cancer, obesity, ongoing pain)
Depression, anxiety, stress, people feeling judged for seeking mental health treatment
Low community involvement, hopelessness, apathy
Injury and violence
Health/safety of indoor and outdoor spaces
Comments:
5.
How difficult is it to receive the following services within your community?
Very difficult
Somewhat difficult
Not at all difficult
I don't know
Mental health
Very difficult
Somewhat difficult
Not at all difficult
I don't know
Addiction services
Very difficult
Somewhat difficult
Not at all difficult
I don't know
Primary care (general care)
Very difficult
Somewhat difficult
Not at all difficult
I don't know
Specialty care (cardiologist, podiatrist, etc.)
Very difficult
Somewhat difficult
Not at all difficult
I don't know
Dental care
Very difficult
Somewhat difficult
Not at all difficult
I don't know
Comments:
6.
Some people choose not to seek help for mental health issues. What do you think is the primary reason people in your community might avoid getting help for mental health issues? (Select ONE)
The treatment is not available or is too far away
The cost of treatment is too high
People worry that others will find out about the issue and/or treatment
Most people who need treatment do not believe they have a problem
People don't know how or where to get this type of treatment
Comments:
7.
If you were seriously injured, how long would it take you to get to a hospital, urgent care, or emergency room for treatment?
5 minutes or less
10 minutes
20 minutes
40 minutes or longer
8.
Do you consider yourself hopeful?
Yes
No
I don't know
9.
Do you have someone that you consider your regular healthcare provider?
Yes
No
I don't know
Comments:
10.
Please indicate if any of the following issues prevented you from accessing health care in the past year (please select all that apply):
The doctor's office wasn't accepting your health insurance
The doctor's office wasn't accepting new patients
You were unable to find transportation
You were unable to afford transportation
You were unable to take or afford time off from work
You were unable to find necessary childcare
The service you needed was too far to access
The cost was too high (insurance deductible, co-pay, lab costs, prescriptions)
Accessing health services was not an issue for me in the past year
Other (please specify)
11.
Please let us know if you or someone in your family were unable to do any of the following within the last year due to the inability to afford the service (please select all that apply):
Fill a prescription
Access primary care
Access specialty care
Access dental care
Access mental health care
Access substance abuse services
Cost was not a barrier to care for me or my family in the past year
12.
What county do you live in?
Athens
Gallia
Meigs
Jackson
Vinton
Other (please specify)
13.
What is your zip code?
14.
Please tell us your age:
Under 18
18-24
25-44
45-64
65+
15.
Please tell us your sex:
Male
Female
16.
What is your marital status?
Single, never married
Married/domestic partnership
Widowed/Widower
Divorced
17.
What is your average yearly household income?
Under $10,000
Between $10,000 and $19,999
Between $20,000 and $29,999
Between $30,000 and $39,999
Between $40,000 and $49,999
Between $50,000 and $59,999
Between $60,000 and $74,999
Between $75,000 and $99,999
Between $100,000 and $149,999
Between $150,000 and $199,999
$200,000 or more
18.
What is your highest level of education?
Less than high school
High school diploma/GED
Some college
Associate degree
Bachelor's degree
Master's degree or higher
19.
What is your current insurance status?
Insurance plan through an employer
Self-purchased insurance plan
Medicare/Medicaid/Other government program
Uninsured
I don't know
Current Progress,
0 of 19 answered