Cattaraugus County Community Health Survey 2013

Demographics

The Cattaraugus County Health Department and its community partners NEED YOU! We are gathering information to help with public health planning for the next four years.

Your input is very important to us! Please take a few minutes to fill out this survey to help us identify gaps and needs in the community so that we can work toward improvement. Thank you for your time and help with this very important effort!

To start, please tell us a little about yourself. Then, please answer some questions about your health. After completion, if you want to give us your name and phone number you will be entered into a drawing to win an iPad!

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* 1. What is your ZIP code?

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* 2. What is your gender?

Male

Female

Other or Do Not Identify

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* 3. What is your age range?

Less than 18

18-29

30-39

40-49

50-59

60-69

70 and over

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* 4. What is your race/ethnicity?

White, non-Hispanic

Black, non-Hispanic

White, Hispanic

Black, Hispanic

American Indian or Alaska Native

Asian or Pacific Islander

Other (please specify)

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* 5. What is your height?

Feet:

Inches:

Cattaraugus County Community Health Survey 2013

Demographics

Question Title

* 1. What is your ZIP code?

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* 2. What is your gender?

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* 3. What is your age range?

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* 4. What is your race/ethnicity?

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* 5. What is your height?

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* 6. What is your weight?

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* 7. How many children (younger than 18 years old) are living in your home?

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* 8. How many adults live in your home (between age 18-64), including yourself?

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* 9. How many seniors live in your home (age 65 and older), including yourself?