* 1. In the following list, what do YOU think are the 3 Most Important Factors for a “Healthy” Bracken County? Those factors which most improve the quality of life in our community). Check up to 3:

* 2. In the following list, what do YOU think are the 3 Greatest Health Problems that must be addressed in Bracken County? (Those concerns which have the greatest impact on overall community health). Check up to 3:

* 3. In the following list, what do YOU think are the 3 Most Risky Behaviors in Bracken County?  Please select those behaviors that YOU believe have the greatest impact on overall community health. Check up to 3:

* 4. How would you rate the overall health of Bracken County?

* 5. How would you rate YOUR own personal health?

* 6. Age:

* 7. Gender:

* 8. Race:

* 9. Are you of Hispanic Ethnicity?

* 10. Marital Status:

* 11. Highest Level of Education Completed:

* 12. Annual Household Income:

* 13. Employment Status:

* 14. Number of ADULTS in your household?

* 15. Number of CHILDREN (less than 18 years old) in your household?

* 16. Number of CHILDREN (greater than 18 years old) in your household?

* 17. Are you a grandparent with grandchildren living in your home?

* 18. How do you pay for your health care?

* 19. In the past 12 months, have you decided NOT to seek health care services because of out-of-pocket cost to you?

* 20. Would you use an Urgent Care located in Bracken County?

* 21. Where do you get your information about health? (Check all that apply)

* 22. Where do you get your information about events/news in Bracken County? (Check all that apply)

* 23. What is the zip code where you live in Bracken County?

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