State of Black Health Pulse Survey

This short survey will help the Department of Health and Human Services understand current health experiences and priorities in the Black Diaspora community in Montgomery County.

Your response is anonymous and will guide future focus groups and planning. It should take about 5-7 minutes to complete.

1.How long have you lived in Montgomery County?

Less than 1 year

1–5 years

6–10 years

More than 10 years

3.What is your current gender identity? (Select all that apply)

Male

Female

Transgender

I do not identify as male or female

4.In what year were you born? (enter 4-digit birth year)

6.Have you ever felt that your racial or cultural background affected the care you received?

Yes

No

Not sure

If yes, how?

7.Overall, do you feel that healthcare providers in this area understand the experiences and needs of people in your community who share your background?

Yes

No

Not sure

8.Do you currently have health insurance?

Yes

No

Not sure

9.If you are the parent/guardian for a child(ren) under 18, do they currently have health insurance?

Yes

No

Not sure

Not parent or guardian for child <18

10.How often do you delay seeing a healthcare provider for yourself or your family due to cost or insurance coverage?

Most of the time

Some of the time

Rarely or never

11.How often do you delay seeing a healthcare provider for yourself or your family due to other reasons?

Most of the time

Some of the time

Rarely or never

12.What is the main reason you delay seeing a healthcare provider?

Other (please specify)

Not applicable (I do not delay seeking care)

The following questions ask about your perception of the experiences of people in your community who share your background.

14.What are the biggest challenges people in your community face when trying to get health care? (Select up to 3)

Other (please specify)

After you submit this survey, you will be automatically redirected to a separate form where you may provide your contact information, if you are interested in participating in a focus group on this topic. Sharing contact information is optional and will not be linked to survey responses.