Clay County Community Health Needs Survey

Please take a few minutes to complete the survey below.

The purpose of this survey is to get your opinions about health issues in our community. This survey is conducted by the Health for Generations Coalition and Clay County Health Department. The results of this survey along with other information will be used for the development of a community health improvement plan for the county in which you reside. Your opinion is important to us! Thank you!

***Note - This survey is anonymous

Part 1: Community Health

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* 1. In the following list, what do you think are the three most important factors for a healthy community? (Those factors which most improve the quality of life in a community.)

Check only three (3):

Good place to raise children

Low crime/safe neighborhoods

Low level of child abuse

Good schools

Access to health care (e.g., family healthcare provider)

Parks and recreation

Clean environment

Affordable housing

Arts and cultural events

Excellent race relations

Good jobs and healthy economy

Strong family life

Healthy behaviors and lifestyles

Low adult death and disease rates

Low infant deaths

Religious or spiritual values

Other (please specify)

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* 2. In the following list, what do you think are the three most important health problems in our community? (Those problems which have the greatest impact on overall community health.)

Check only three (3):

Aging problems (e.g., arthritis, hearing/vision loss, etc.)

Cancers

Child abuse / neglect

Dental problems

Diabetes

Domestic Violence

Firearm-related injuries

Farm-related injuries

Heart disease and stroke

High blood pressure

HIV / AIDS

Homicide

Infant Death

Infectious Diseases (e.g.,hepatitis, TB, etc.)

Mental health problems

Motor vehicle crash injuries

ATV injuries

Rape / sexual assault

Respiratory / lung disease

Sexually Transmitted Diseases (STDs)

Suicide

Teenage pregnancy

Other (please specify)

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* 3. In the following list, what do you think are the three most important risky behaviors in our community? (Those behaviors which have the greatest impact on overall community health.)

Check only three (3):

Alcohol abuse

Being overweight

Dropping out of school

Drug abuse

Lack of exercise

Poor eating habits

Not getting shots to prevent disease

Tobacco use

Not using birth control

Not using seat belts / child safety seats

Unsafe sex

Poor parenting

Lack of life skills (money mgmt., cooking, etc.)

Other (please specify)

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* 4. How would you rate our community as a “Healthy Community?”

Very unhealthy

Unhealthy

Somewhat healthy

Healthy

Very healthy

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

Very unhealthy

Unhealthy

Somewhat healthy

Healthy

Very healthy

Part 2: Housing

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* 6. How often in the past 12 months would your household say they were worried or stressed about having enough money to pay your rent/mortgage? Would you say you were worried or stressed-

Always

Usually

Sometimes

Rarely

Never

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* 7. Do you feel your home is currently physically safe to live in?

Yes

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* 8. If No, why not? Choose all that apply

Structural hazards

Pestilence (bugs, mice, termites, etc.)

Air quality (smoking, mold, mildew)

Fear of future disaster

Other (please specify)

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* 9. What type of structure is your home?

Single Family

Multiple unit (apartment, duplex, etc.)

Mobile Home

Other (please specify)

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* 10. How many people are currently living in your household

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* 11. How many people living in your household are:

Less than 4 years old?

4-17 years old?

18-65 years old?

More than 65 years old?

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* 12. Does your household have a working smoke detector?

Yes

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* 13. Does your household have a working carbon monoxide detector?

Yes

Part 3 - Health Status

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* 14. How often do you seek medical attention?

Approximately every 3 months

Twice yearly (every 6 months)

Yearly

Rarely (More than 2 years since last visit)

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* 15. What is the most significant barrier for seeking medical attention for you and or your family? (Choose all that apply.)

Unable to get appointment

Inconvenient provider office hours

Distance

Lack of transportation

Unable to get off work

Cost

Other (please specify)

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

Self-pay

Health insurance

Medicaid or Allkids

Medicare

Veterans’ Administration

Other (please specify)

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* 17. Do you have one person / clinic you think of as your primary health care provider?

Yes, only one.

More than one.

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* 18. Have you or a member of your household ever been told by a healthcare professional that you or he/she has: (Choose all that apply)

Asthma/COPD/Emphysema

Diabetes

Developmental disability

Hypertension/Heart disease

Auto-immune disease/Immuno-suppressed

Physical disability

Psychosocial/Mental illness

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* 19. Has a health care provider ever discussed cancer risk or early detection cancer screenings with you or a member of your household?

Yes

I don't know

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* 20. Do you or does any member of your household currently use…… (Choose all that apply.)

Daily medication

Dialysis

Home Health Care

Oxygen

Wheelchair/cane/walker

Other special care

Part 4: Mental Health Status

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* 21. Thinking about your mental health, which includes stress, depression, and problems with emotions, for how many days during the past 30 days was your mental health not good?

20 or more days

10 - 20 days

5 - 10 days

1 - 5 days

0 days

Part 5: Oral Health Status

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* 22. How would you rate your oral health status?

Excellent

Very good

Fair

Poor

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* 23. Do you have a regular dental provider?

Yes

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* 24. What is the most significant barrier to seeking regular dental care? (Choose all that apply)

Unable to get appointment

Inconvenient provider office hours

Distance

Fear / Anxiety / Perception of Pain

Lack of transportation

Unable to get off work

Cost

Other (please specify)

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* 25. How do you pay for you and your family's dental care?

Self-pay

Dental insurance

Medicaid or Allkids

Veterans' Administration

Other (please specify)

Part 6 - Drug/Substance Use and/or Abuse

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* 26. How concerned are you with prescription drug abuse in your community?

Very concerned

Concerned

Somewhat concerned

Not at all concerned

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* 27. How concerned are you with illegal drug use in your community?

Very concerned

Concerned

Somewhat concerned

Not at all concerned

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* 28. In the past 12 months, how many members of your household have tried to quit smoking cigarettes (or using a tobacco product)?:

Other (please specify)

Part 7 - Alcohol Use

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* 29. During the past 30 days, how many days per week did you have at least one drink of any alcoholic beverage such as beer, wine, a malt beverage or liquor?

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* 30. Considering all types of alcoholic beverages, how many times during the past 30 days did you have 4 or more drinks on one occasion?

Part 8 - Nutrition and Exercise

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* 31. How many times a week do you exercise?

I don't exercise

1-2 times/week

3-6 times/week

More than 6 times per week

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* 32. Is there anything that prevents your household from exercising?
Check all that apply:

Expensive

Don't have time

Limited gym options

Distance

Physical Disability

Don't want to

N/A -nothing prevents

Other (please specify)

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* 33. How often in the past 12 months would your household say they were worried or stressed about having enough money to buy food? Would you say you were worried or stressed -

Always

Usually

Sometimes

Rarely

Never

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* 34. During the past month, not counting juice, how many times did you eat fruit?

1-2 times a week

3-4 times a week

4 or more times a week

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* 35. During the past month, how many times did you eat vegetables?

1-2 times a week

3-4 times a week

4 or more times a week

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* 36. How many days during the last 7 days did you or a member of your household eat a meal from a restaurant or other food vender?

1-2

3-4

5-6

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* 37. Is there anything that prevents your household from eating nutritious food?
Check all that apply:

Local availability

Expensive

Local selection quality

Don’t want to

Time for preparing

N/A – nothing prevents

Other (please specify)

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* 38. Are you satisfied with the quality of life in our community? (Consider your sense or safety, well-being, participation in community life and associations, etc.)

Yes

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* 39. Is there economic opportunity in the community? (Consider locally owned and operated businesses, jobs with career growth, job training/higher education opportunities, affordable housing, reasonable commute, etc.)

Yes

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* 40. Do you feel the community is a safe place to live? (Consider resident's perceptions of safety in the home, the workplace, schools, playgrounds, parks, and the mall. Do neighbors know and trust one another? Do they look out for one another?)

Yes

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* 41. Does the community offer networks of support for individuals and families during times of stress and need? (such as neighbors, support groups, faith community outreach, agencies, organizations)

Yes

Part 9 - Emergency Preparedness

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* 42. Has your household prepared an Emergency Supply Kit with supplies like water, food, flashlights, and extra batteries that is kept in a designated place in your home?

Yes

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* 43. If your household had to evacuate due to a large scale disaster or emergency, where would you go?
Check only one (1) please:

Friends/family/2nd home outside of area

Hotel or motel

American Red Cross, church or community shelter

Would not evacuate

Other (please specify)

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* 44. Does your household have any emergency plans, such as a list of emergency contact numbers and designated out-of-town contacts, designated meeting place, copies of important documents in a safe location?

Yes

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* 45. What would be the main reason that might prevent you from evacuating? Check only one (1) please:

Lack of transportation

Lack of trust in public officials

Concern about leaving property

Nowhere to go

Concern about personal safety

Concern about pets/livestock

Concern about traffic

Inconvenience/expensive

Health problems

N/A

Other (please specify)

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* 46. Does your household currently have a 7 day supply of medication for each person who takes prescribed meds?

Yes

N/A

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* 47. Where would you first look for reliable information regarding a disaster?

Neighbor, word of mouth

Text message

Internet or Social Media

Flyer/poster

Local newspaper

Radio station

Other (please specify)

Part 10 - Demographics

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* 48. Zip Code of City/Village where you live

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* 49. Age

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* 50. Sex

Male

Female

Other (please specify)

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* 51. Ethnic group you most identify with

African American/Black

Asian/Pacific Islander

Hispanic/Latino

Native American

White/Caucasian

Two or more

Other (please specify)

THANK YOU FOR YOUR TIME!

Question Title

* 1. In the following list, what do you think are the three most important factors for a healthy community? (Those factors which most improve the quality of life in a community.)Check only three (3):

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* 2. In the following list, what do you think are the three most important health problems in our community? (Those problems which have the greatest impact on overall community health.)Check only three (3):

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* 3. In the following list, what do you think are the three most important risky behaviors in our community? (Those behaviors which have the greatest impact on overall community health.)Check only three (3):

Question Title

* 4. How would you rate our community as a “Healthy Community?”

Question Title

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

Question Title

* 6. How often in the past 12 months would your household say they were worried or stressed about having enough money to pay your rent/mortgage? Would you say you were worried or stressed-

Question Title

* 7. Do you feel your home is currently physically safe to live in?

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* 8. If No, why not? Choose all that apply

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* 9. What type of structure is your home?

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* 10. How many people are currently living in your household

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* 11. How many people living in your household are:

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* 12. Does your household have a working smoke detector?

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* 13. Does your household have a working carbon monoxide detector?

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* 14. How often do you seek medical attention?

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* 15. What is the most significant barrier for seeking medical attention for you and or your family? (Choose all that apply.)

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

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* 17. Do you have one person / clinic you think of as your primary health care provider?

Question Title

* 18. Have you or a member of your household ever been told by a healthcare professional that you or he/she has: (Choose all that apply)

Question Title

* 19. Has a health care provider ever discussed cancer risk or early detection cancer screenings with you or a member of your household?

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* 20. Do you or does any member of your household currently use…… (Choose all that apply.)

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* 21. Thinking about your mental health, which includes stress, depression, and problems with emotions, for how many days during the past 30 days was your mental health not good?

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* 22. How would you rate your oral health status?

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* 23. Do you have a regular dental provider?

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* 24. What is the most significant barrier to seeking regular dental care? (Choose all that apply)

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* 25. How do you pay for you and your family's dental care?

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* 26. How concerned are you with prescription drug abuse in your community?

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* 27. How concerned are you with illegal drug use in your community?

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* 28. In the past 12 months, how many members of your household have tried to quit smoking cigarettes (or using a tobacco product)?:

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* 29. During the past 30 days, how many days per week did you have at least one drink of any alcoholic beverage such as beer, wine, a malt beverage or liquor?

Question Title

* 30. Considering all types of alcoholic beverages, how many times during the past 30 days did you have 4 or more drinks on one occasion?

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* 31. How many times a week do you exercise?

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* 32. Is there anything that prevents your household from exercising? Check all that apply:

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* 33. How often in the past 12 months would your household say they were worried or stressed about having enough money to buy food? Would you say you were worried or stressed -

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* 34. During the past month, not counting juice, how many times did you eat fruit?

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* 35. During the past month, how many times did you eat vegetables?

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* 36. How many days during the last 7 days did you or a member of your household eat a meal from a restaurant or other food vender?

Question Title

* 37. Is there anything that prevents your household from eating nutritious food? Check all that apply:

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* 38. Are you satisfied with the quality of life in our community? (Consider your sense or safety, well-being, participation in community life and associations, etc.)

Question Title

* 39. Is there economic opportunity in the community? (Consider locally owned and operated businesses, jobs with career growth, job training/higher education opportunities, affordable housing, reasonable commute, etc.)

Question Title

* 40. Do you feel the community is a safe place to live? (Consider resident's perceptions of safety in the home, the workplace, schools, playgrounds, parks, and the mall. Do neighbors know and trust one another? Do they look out for one another?)

* 1. In the following list, what do you think are the three most important factors for a healthy community? (Those factors which most improve the quality of life in a community.)

Check only three (3):

* 2. In the following list, what do you think are the three most important health problems in our community? (Those problems which have the greatest impact on overall community health.)

Check only three (3):

* 3. In the following list, what do you think are the three most important risky behaviors in our community? (Those behaviors which have the greatest impact on overall community health.)

Check only three (3):

* 32. Is there anything that prevents your household from exercising?
Check all that apply:

* 37. Is there anything that prevents your household from eating nutritious food?
Check all that apply:

* 43. If your household had to evacuate due to a large scale disaster or emergency, where would you go?
Check only one (1) please: