Community Health Needs Assessment Survey

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* 1. What is your zipcode?

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* 2. What is your gender?

Male

Female

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* 3. What is your race?

White

Black or African American

American Indian or Alaska Native

Asian

Hispanic or Latino

Native Hawaiian and Other Pacific Islander

Other

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* 4. How long have you lived in the area?

Less than 1 year

1-2 years

3-5 years

6-10 years

11-20 years

More than 20 years

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* 5. How many people live in your household?

One

Two

Three to five

Six to eight

More than eight

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* 6. Are any of them children between 0 and 17 years old?

Yes

No. If “No”, please skip to question 26.

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* 7. How many children in your household are between...

0-5 years old?

6-13 years old?

14 – 17 years old?

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* 8. Have any of the children in your household been told by a doctor that they have one of the following conditions? (check all that apply)

Asthma

Diabetes

Overweight or obesity

Autism Spectrum Disorder

Attention Deficit Disorder (ADD) or Attention Deficit Hyperactivity Disorder (ADHD)

None of the above

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* 9. If a child in your household has asthma, how many times during the past 12 months did you visit an emergency room because of the asthma?

None

One time

Two times

Three or more times

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* 10. If a child in your household has diabetes, how many times during the past 12 months did you visit an emergency room because of the diabetes?

None

One time

Two times

Three or more times

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* 11. Has a child in your household used the following? (check all that apply)

Alcohol

Drugs

Tobacco

None of the above

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* 12. Has a child in your household (age 17 or younger) become pregnant?

Yes

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* 13. Is any child in your household in fair to poor health?

Yes

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* 14. How long has it been since the children in your household last visited a doctor for a routine checkup? (A routine checkup is a general visit, not a visit for a specific illness, injury, or condition.)

Within in the past year

Within the past two years

Within the past five years

Five or more years ago

Never

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* 15. If their last visit was longer than one year ago, is it because:

They do not have a medical condition that requires care and they receive health screenings from another provider.

They do not receive any health screenings.

Could not schedule due to work or personal conflicts within normal business hours.

Could not afford the payments due, regardless of insurance status.

Could not arrange transportation

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* 16. If the children in your household have a health care need: (answer all that apply)

Do they have a doctor they can go to? Yes or No

Do they have a dentist they can go to? Yes or No

Do they have a mental health specialist they can go to? Yes or No

Do they have a substance abuse counselor they can go to? Yes or No

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* 17. Have your children had all of their immunizations on time?

Yes

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* 18. If no to question 17, is it because:

You do not believe in immunizations

You could not afford the immunizations

You could not find a provider to give the immunizations

You didn’t know you needed to have them immunized

Other (please specify)

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* 19. How many times during the past 12 months have any of the children in your household used a hospital emergency room?

None

1-2 times

3-5 times

more than 5 times

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* 20. If any of your children went to a hospital emergency room in the last 12 months, was it due to:

They had an injury that required immediate attention.

They had an injury that did not require immediate attention but it was the most convenient/only service available

An ongoing illness.

Other (please specify)

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* 21. Have you had any difficulty finding a doctor for any of the children in your household in the past two years?

Yes

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* 22. If yes to question 21, why would you say you had trouble finding a doctor?

Couldn’t get a convenient appointment

Didn’t know how to get in contact with one

Doctor was not taking new patients

No transportation

Would not accept your insurance

Other (please specify)

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* 23. Have you had any difficulty finding a doctor for your child/children that treats specific illnesses or conditions in your area in the past two years?

Yes

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* 24. If yes to question 23, what kind of specialist did you look for? (check all that apply)

Bone or joint specialist

Cancer specialist

Dentist

Diabetes specialist

Heart specialist

Lung/breathing specialist

Mental health specialist

Nerve and brain specialist

Other (please specify)

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* 25. Why were you unable to visit the specialist when your child needed one?

No appointments were available

No specialist was available in the area

Did not have a car or transportation to get to their office

Could not get to the office when they were open

Did not know how to find one

The specialist would not take my insurance

Could not afford to pay for the specialist

Other (please specify)

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* 26. What do you think are the most pressing health problems facing children in the community? (check all that apply)

Ability to pay for health care services

Alcohol dependency or abuse

Drug abuse – prescription medications

Drug abuse – illegal substances

Child abuse

Domestic violence

Lack of health insurance

Lack of transportation to health services

Lack of dental care

Mental Health

Obesity

Prescription medicine is too expensive

Teen pregnancy

Tobacco use/smoking among teenagers

Other (please specify)

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* 27. What medical services for children (0-17 years of age) are most needed in the community?

Alcohol and drug abuse treatment

Counseling/mental health services

Diabetes care

Dental services

Emergency/trauma care

Pediatricians

Pediatric specialists

Special education for children with developmental disabilities

Specialized resources for children with Autism Spectrum Disorder

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* 28. What health or community services should CHOC provide that currently are not available?

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* 29. What ideas or suggestions do you have for improving the overall health of the area community?

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* 30. What is your highest level of education?

Left high school without a diploma

High school diploma

GED

Currently attending, or have some college

Two-year college degree

Four-year college degree

Graduate-level degree

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* 31. Including yourself, how many adults (18 years or older) live in your household?

One

Two

Three

Four

Five or more

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* 32. Including yourself, how many adults (18+) are employed full-time, year-round?

One

Two

Three

Four

Five or more

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* 33. How many household members are covered by insurance?

Adults

Children

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* 34. If there are children in your household that have health insurance, how is it obtained? (check all that apply)

Medi-cal

Through an employer’s health plan

Privately purchased

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* 35. Counting all income sources from everyone in your household, what was the combined household income last year? (check only one)

Less than $20,000

$20,000 to $29,999

$30,000 to $39,999

$40,000 to $49,999

$50,000 to $59,999

$60,000 to $69,999

$70,000 to $99,999

$100,000 to $199,999

$200,000 or more

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* 36. How would you describe your housing situation? (check only one)

Own a house or condo

Rent a house, apartment, or a room

Living in a group home

Living temporarily with a friend or relative

Multiple households sharing an apartment or a house

Living in a shelter

Living in a motel

Living in senior housing or assisted living

Other (please specify)

Household issues – Some of the following may have been a problem for you or someone in your household (adults and/or children). If it has been a problem in your household during the past 12 months, please tell us how much of a problem it has been. (Check one on each line for questions 37 - 54.)

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* 37. Adult substance abuse (alcohol or legal medications)

Not a problem

Minor problem

Major problem

Don’t know

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* 38. Adult substance abuse (illegal drugs)

Not a problem

Minor problem

Major problem

Don’t know

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* 39. Youth substance abuse (alcohol, drugs, etc. A. Not a problem

Not a problem

Minor problem

Major problem

Don’t know

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* 40. Caring for an adult with disabilities

Not a problem

Minor problem

Major problem

Don’t know

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* 41. Caring for a child with disabilities

Not a problem

Minor problem

Major problem

Don’t know

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* 42. Child abuse

Not a problem

Minor problem

Major problem

Don’t know

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* 43. Depression

Not a problem

Minor problem

Major problem

Don’t know

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* 44. Not having enough money for food

Not a problem

Minor problem

Major problem

Don’t know

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* 45. Not able to afford nutritious food (fresh vegetables and fruits)

Not a problem

Minor problem

Major problem

Don’t know

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* 46. Not able to afford transportation

Not a problem

Minor problem

Major problem

Don’t know

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* 47. Not having enough money to pay for housing

Not a problem

Minor problem

Major problem

Don’t know

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* 48. Not having enough money to pay the doctor, dentist or pharmacy

Not a problem

Minor problem

Major problem

Don’t know

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* 49. Not having enough money to pay for mental health services

Not a problem

Minor problem

Major problem

Don’t know

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* 50. Use of tobacco products

Not a problem

Minor problem

Major problem

Don’t know

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* 51. Not being able to find or afford after-school child care

Not a problem

Minor problem

Major problem

Don’t know

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* 52. Sexual abuse

Not a problem

Minor problem

Major problem

Don’t know

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* 53. Teen pregnancy

Not a problem

Minor problem

Major problem

Don’t know

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* 54. If other household issue, please specify:

Please click the button below to submit your answers.

Thank you for taking the time to fill out this survey. Your opinion is important to us.