Community Health-Public Input Survey

Demographics

This survey will take less than 5 minutes to complete.

There is no way for people to see who provided information. Survey information is ANONYMOUS.

Question Title

* 1. Zip code and City or Town

Zip code (5 digits please)

City or Town

Question Title

* 2. Gender

Male

Female

Other

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* 3. Age

Age

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* 4.

	Hispanic	Non-Hispanic	Other	Not Answered
Black	Black Hispanic	Black Non-Hispanic	Black Other	Black Not Answered
White	White Hispanic	White Non-Hispanic	White Other	White Not Answered
Asian	Asian Hispanic	Asian Non-Hispanic	Asian Other	Asian Not Answered
Other	Other Hispanic	Other Non-Hispanic	Other Other	Other Not Answered
Not Answered	Not Answered Hispanic	Not Answered Non-Hispanic	Not Answered Other	Not Answered Not Answered

Question Title

* 5. Estimated 2012 household income

Less than 25,000

25,000 to 39,000

40,000 to 59,000

Over 60,000

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* 6. Employment Status

Employed

Unknown

Unemployed

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* 7. Number of people living in your household (include yourself)

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* 8. Are you a main caregiver? (select all that apply)

No

Yes,to my children

Yes,to my grandchildren

Yes, to my parents

Other

Other (please specify)

Question Title

* 9. Do you have health insurance?

Yes

No