The Tehama County Maternal Child Adolescent Health Program is doing this survey as part of a community needs assessment to help us to find out more about health needs in our communities. Please answer the questions as honestly as possible. This survey is completely anonymous -- do not put you name anywhere on this form.
Thank you for taking this survey to help us learn more about the health of our community. We will use the information we get to better plan and develop services for women, children and families in our communities. Your input is very important to us.
Please complete this survey if you live in Tehama county and are:
• A woman who has been pregnant during the past 3 years, is now pregnant or think you may be
pregnant during the next 3 years
• A parent of (or persons responsible for) a child or children under 18 living in your home (includes
foster parent, guardian, grandparent or other family member with whom the child lives)
• The spouse or significant other of a woman who is now pregnant or has been pregnant in the past 3
years
Please fill out only one survey per household.
Thank you for completing this survey.