Please take a moment to complete the survey. The purpose of the survey is to obtain your input about the community health problems/issues and quality of life in Stephens/Jefferson County, OK. The results of the survey will assist in identifying the most pressing concerns that can be addressed through community action.

Please complete the survey only once. Your opinion is important! The survey is voluntary. All information will be kept confidential. The survey will take approximately 10-15 minutes to complete. If you have any questions, or need assistance with completion of the survey, contact information is included at the end of the survey. Please answer the following questions below as they relate to Stephens/Jefferson County. For the purposes of this survey Community is defined as “Stephens/Jefferson County”.

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* 1. Zip Code of where you live:

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* 2. Length of residence in Stephens/Jefferson County

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* 3. Sex

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* 4. Age

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* 5. Marital Status

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* 6. What is this person's ethnicity?

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* 7. What is this person's race?  Mark one or more races to indicate what this person considers himself/herself to be.

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* 8. Education

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