Local Primary Care Needs Assessment Question Title * 1. Thank you for taking part in this survey. The information we gather will be grouped for feedback to each Chapter. Your answers will help us obtain additional resources to improve health services in our communities. Our goal is to find out what type of basic health problems are in your community and what you may feel are community needs.Your personal information is not collected or shared. Answering each question is helpful but you DO NOT have to answer each question. This is a totally voluntary survey. Question Title * 2. Please add today's date. MM/DD/YYYY Date Question Title * 3. Please indicate your Chapter/Community Bodaway/Gap Cameron Coalmine Coppermine K'ai'bii'to Lechee Moenave Tuba City San Juan Paiute Other (please specify) Question Title * 4. What is your gender? Female Male Question Title * 5. What language(s) do you speak? English Hopi Navajo Other (please specify) Question Title * 6. Are you the head of the household? Yes No Question Title * 7. What is your age? Question Title * 8. What is your current marital status? Single Never married Unmarried partnership Married Divorced Separated Widowed Question Title * 9. What is the highest level of school you have completed or the highest degree you have received? 8th grade or less Some High School - did not graduate High School or GED Vocational Certification Associate Degree Baccalaurate (Bachelor) Degree Graduate (Masters or Doctorate) Degree Post Graduate Other (please specify) Question Title * 10. Are you employed with regular paychecks? Full-Time Part-Time Unemployed Student Retired Other (please specify) Question Title * 11. What is your primary occupation? Agriculture(forestry, fishing, or hunting) Artist Construction Education/Schools Health Care Homemaker Information Technology Jewelry Manufacturing Mining Office/administrative Rancher/farmer Retail trade Retired Semi skilled/aide/cook Skilled labor/craft/clerical Skilled supervisor/foreman Transportation,warehousing, or utilities Unskilled labor Wholesale trade Other (please specify) Question Title * 12. How long have you been employed? Years Not Applicable Question Title * 13. Reason(s) why you are not working or unable to work: physical health problem mental health problem looking for work no jobs available caretaker of family not looking for work elderly Other (please specify) Question Title * 14. How many people currently live in your household? Question Title Health Status Questions. Question Title * 15. How would you describe your current physical health? Very Good (Excellant) Good Fair Poor Very Poor I don't know Next
