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* 1. What is the Zip code of your residence?

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* 2. What gender do you identify with?

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* 3. What is your Ethnicity?

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* 4. What race group do you most identify with?

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* 5. What is your age?

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* 6. What is your highest level of education?

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* 7. What is your employment status?

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* 8. What is your household income?

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* 9. Are you able to get medication when needed?

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* 10. Are you able to get medical care for:

  Yes No Not Applicable
General Medical Care for Adults
General Medical Care for Children
Female-Specific Care, such as OB/GYN, breast exams, etc.
Male-Specific Care, such as prostate screening
Teeth for Adults
Teeth for Children
Eyes for Adults
Eyes for Children
Mental Health Services for Adults
Mental Health Services for Children

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* 11. How do you pay for health care? (Select all that apply)

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* 12. Has your household used any healthcare services over the past 12 months?

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* 13. At which healthcare facility did you receive services? (Select all that apply)

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* 14. Do you feel confident you have been provided clear health information to make good decisions about preventing chronic diseases from happening or getting worse? (Diabetes, High Blood Pressure, etc.) (Select one)

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* 15. Have you had any of the following cancer screenings within the past 12 months? (Select all that apply)

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* 16. If you did not have a screening, what prevented you from having a cancer screening within the past 12 months? (Select all that apply)

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* 17. How would you rate Stephens or Jefferson County as a "Healthy Community"? (Select One)

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* 18. What concerns you most about the health in your community? (Select all that apply)

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* 19. What are 3 things that cause you the most stress? (Select only 3)

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* 20. How far are you able to travel for healthcare services?

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* 21. In your opinion, which of the following would make it easier for you to access healthcare services? (Select all that apply)

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* 22. How do you prefer to receive information about services or community events? (Select all that apply)

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* 23. What is your comfort level with accessing healthcare services using the internet? (Viewing personal health records, etc)

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* 24. Do you have access to internet?

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* 25. What is the main reason you do not have internet? (Select all that apply)

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* 26. Are food programs, like a food banks, churches, and donation boxes, a need for your community?

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* 27. Where do you get food/groceries? (Select all that apply)

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* 28. Please Answer the following:

  Strongly Agree Agree Neutral Disagree Strongly Disagree I don't know
Scheduling a healthcare appointment in my community is easy
Transportation to a healthcare appointment in my community is easy
There are healthcare workers within my community who are available to help connect me with services
There are jobs available within my community
Jobs pay enough for people to live on, this includes housing, food, transportation, medical care
It is easy to get affordable fresh fruits and vegetables in my community year-round
My community has affordable housing
Homelessness within my community is a problem
Support networks are available for older individuals and families in my community
Support networks are available for younger individuals and families in my community
My community is a hopeful place
There are safe opportunities for me to be physically active within my community
There is affordable childcare in my community
I am satisfied with the school system in my community
After-school programs within my community meet our household needs

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* 29. Please Answer these Questions about your County:

  Yes No Not Aware
Is this county a good place to raise children?
Is this county a good place to retire?
Is this county a safe place to live?
Do residents feel they can make the county a better place to live?

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* 30. When I need help, I know how to access the social/community resources listed below.

  Strongly Agree Agree Neutral Disagree Strongly Disagree I don't know
Mental Health
Food
Shelter
Utilities
Transportation
Social Activities

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* 31. Do you have a family disaster plan (Natural or Man-Made)?

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* 32. Do you feel Stephens or Jefferson County is prepared in the event of a disaster (Natural or Man-Made)?

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* 33. Does your household maintain emergency food and supplies in the event of a disaster (Natural or Man-Made)?

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* 34. Please share any additional comments.

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