Community Engagement Question Title * 1. What county do you live in? OK Question Title * 2. My zip code is: OK Question Title * 3. I have this type of health care coverage: Private/Employer-Sponsored Insurance Affordable Care/Obamacare/Marketplace Medicaid Medicare No Insurance Other (please specify) OK Question Title * 4. A doctor, nurse, or other healthcare provider, told me that I have the following: (Check all that apply) High blood pressure High blood sugar (diabetes) High cholesterol None of the above OK Question Title * 5. My main form of transportation is: Bicycle Bus Car Taxi Walk Other (please specify) OK Question Title * 6. I think these are 3 main reasons why people in our community do not seek health care: Cannot get time off Does not know where to go Hours not convenient No one to keep children Not sick No family doctor No insurance No way to get there Fear Other (please specify) OK Question Title * 7. I think these are 3 main reasons that prevent people from being physically active in our community: Crime Heat/Cold No community events No street lights No parks/outdoor spaces Traffic Not enough bike lanes Not enough sidewalks Personal choice Stray dogs/animals Too tired after work Other (please specify) OK Question Title * 8. I think these are 3 main reasons that prevent people in our community from eating healthy foods: Don’t cook at home Eats fast food regularly No community gardens No farmers markets No grocery store near by Too expensive Stores don’t accept SNAP/EBT/WIC Stores don’t have quality produce May not know how to eat healthy Too tired after work Other (please specify) OK Question Title * 9. I think these are the 3 most important health concerns in our community: Alcohol use Alzheimer’s/Dementia Arthritis Cancer Diabetes Drug Use Heart disease/Stroke High blood pressure HIV/AIDS/STDs Infant death Mental health Overweight/Obesity Tobacco use Other (please specify) OK Question Title * 10. I think these are the 3 most important factors for a healthy community: Acceptance of all people Access to affordable healthcare Access to affordable and healthy foods Access to safe places to be active Clean environment Good jobs/healthy economy Good schools Low crime Low disease rates Neighbors helping neighbors Smoke free work place Strong faith and fellowship Other (please specify) OK Question Title * 11. I would rate the overall health of our community as: Poor Fair Good Very good Excellent OK Question Title * 12. I use the following tobacco products. (Check all that apply) I don’t use tobacco products Chew tobacco, dip, snuff, snus Cigarettes Cigars or little cigars Pipes Alternative tobacco products (e-cigs, or electronic cigarettes) OK Question Title * 13. I agree with the idea of smoke free workplaces, including restaurants and bars. Yes No OK Question Title * 14. I am exposed to secondhand smoke (i.e. smoke from someone else who may be smoking in my home, workplace, or public place). Yes No OK Question Title * 15. If you are exposed to secondhand smoke, where? (Check all that apply): Vehicle Home Work I am not expose to secondhand smoke Other (please specify) OK Question Title * 16. In the last 2 days, how many fruits and vegetables have you eaten? None 1-2 3-4 5 or more Other (please specify) OK Question Title * 17. In the last week, how many times were you physically active or exercised? None 1-2 3-4 5 or more OK Question Title * 18. How important is it to be physically active or exercise? Not important Important Extremely important OK Question Title * 19. How important is it to eat fruits and vegetables? Not important Important Extremely important OK Question Title * 20. In the last 30 days when I bought fruits and vegetables, they were? (Check all that apply) Fresh Frozen Canned Can't afford to buy OK Question Title * 21. What age range are you? 18-25 26-39 40-54 55-64 65 or older OK Question Title * 22. Are you male or female? Male Female OK Question Title * 23. Which race/ethnic group do you most identify with? (Choose only one) White Black or African American American Indian or Alaska Native Native Hawaiian or Pacific Islander Asian More than one race Some other race OK Question Title * 24. Are you of Hispanic, Latino or Spanish origin? Yes No OK Question Title * 25. What is your current employment status? (Choose all that apply) Employed for wages Self-employed Out of work and not currently looking for work Out of work and looking for work A homemaker Student Military Retired Unable to work OK Question Title * 26. What was your total family income last year before taxes? (Choose only one) Less than $25,000 $25,000 - $39,999 $40,000 - $59,999 $60,000 - $79,999 $80,000 - $99,999 $100,000 or more OK Question Title * 27. What is the highest level of school, college, or vocational training you finished? (Choose only one) Did not finish high school High school graduate (or GED) Technical college Bachelor’s degree Graduate Degree Doctorate or higher Other (please specify) OK DONE