Community Engagement Survey

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* 3. I have this type of health care coverage:

Private/Employer-Sponsored Insurance

Affordable Care/Obamacare/Marketplace

Medicaid

Medicare

No Insurance

Other (please specify)

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* 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

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* 5. My main form of transportation is:

Bicycle

Bus

Car

Taxi

Walk

Other (please specify)

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* 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)

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* 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)

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* 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)

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* 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)

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* 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)

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* 11. I would rate the overall health of our community as:

Poor

Fair

Good

Very good

Excellent

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* 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)

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* 13. I agree with the idea of smoke free workplaces, including restaurants and bars.

Yes

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* 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

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* 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)

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* 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)

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* 17. In the last week, how many times were you physically active or exercised?

None

1-2

3-4

5 or more

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* 18. How important is it to be physically active or exercise?

Not important

Important

Extremely important

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* 19. How important is it to eat fruits and vegetables?

Not important

Important

Extremely important

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* 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

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* 21. What age range are you?

18-25

26-39

40-54

55-64

65 or older

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* 22. Are you male or female?

Male

Female

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* 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

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* 24. Are you of Hispanic, Latino or Spanish origin?

Yes

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* 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

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* 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

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* 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)

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* 1. What county do you live in?

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* 2. My zip code is:

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* 3. I have this type of health care coverage:

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* 4. A doctor, nurse, or other healthcare provider, told me that I have the following: (Check all that apply)

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* 5. My main form of transportation is:

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* 6. I think these are 3 main reasons why people in our community do not seek health care:

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* 7. I think these are 3 main reasons that prevent people from being physically active in our community:

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* 8. I think these are 3 main reasons that prevent people in our community from eating healthy foods:

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* 9. I think these are the 3 most important health concerns in our community:

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* 10. I think these are the 3 most important factors for a healthy community:

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* 11. I would rate the overall health of our community as:

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* 12. I use the following tobacco products. (Check all that apply)

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* 13. I agree with the idea of smoke free workplaces, including restaurants and bars.

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* 14. I am exposed to secondhand smoke (i.e. smoke from someone else who may be smoking in my home, workplace, or public place).

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* 15. If you are exposed to secondhand smoke, where? (Check all that apply):

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* 16. In the last 2 days, how many fruits and vegetables have you eaten?

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* 17. In the last week, how many times were you physically active or exercised?

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* 18. How important is it to be physically active or exercise?

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* 19. How important is it to eat fruits and vegetables?

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* 20. In the last 30 days when I bought fruits and vegetables, they were? (Check all that apply)

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* 21. What age range are you?

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* 22. Are you male or female?

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* 23. Which race/ethnic group do you most identify with? (Choose only one)

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* 24. Are you of Hispanic, Latino or Spanish origin?

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* 25. What is your current employment status? (Choose all that apply)

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* 26. What was your total family income last year before taxes? (Choose only one)

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* 27. What is the highest level of school, college, or vocational training you finished? (Choose only one)