This survey is intended to gather your feedback and input about health needs in the community where you live. The results will be used to identify the most pressing concerns that can be addressed through the community working together. Thank you!
Significant Community Health Concerns
In each category, select the priority health concern(s) in your community. (Please check only the number shown.)

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* 1. Health Status (Choose ONE)

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* 2. Disease/Health Conditions (Choose TWO)

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* 3. Health Behaviors (Choose THREE)

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* 4. Neighborhood and Environment (Choose TWO)

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* 5. Economic Stability (Choose TWO)

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* 6. Causes of Early Death (Choose ONE)

Responding to Community Health Needs

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* 7. Which of the following would have the biggest impact on the health concerns you identified above? (Choose THREE)

General Demographic Information:

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* 8. Where you live:

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* 9. Sex:

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* 10. Age:

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* 11. Race/Ethnicity:

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* 12. Primary Language:

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* 13. Education:

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* 14. Household Income:

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* 15. Number of People in Home:

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* 16. Employment:

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