How Healthy is Our Community Question Title * 1. Check up to 5 selections you feel are the most important features of a healthy community. Access to churches or other places of worship Access to healthcare Access to parks and recreation Adequate accommodations for persons with disabilities Affordable and/or available housing options Clean environment Equality among different racial/ethnic groups Good job, health economy Good public transportation Good education Low crime rates / safe neighborhoods Low death and disease rates Preventative health services Quality childcare Quality social services Other (please specify) Question Title * 2. Check up to 5 behaviors you are most concerned about in your community. Alcohol abuse Access to food Juvenile deliquency Drug abuse Being overweight/obese Dropping out of school Violence Lack of preventative activities (IE - cancer screening, etc) Lack of exercise Teen sexual activity Racism Not getting vaccines to prevent disease Not using birth control Poor eating habits Child safety issues Tobacco use (IE cigarettes, chewing tobacco, e-cigarettes) Unsafe sex Other Question Title * 3. What are barriers for accessing healthcare in your community? Is this a barrier? Lack of transportation This is a barrier This is NOT a barrier I don't know Lack of transportation Is this a barrier? menu Can't pay for services/medication This is a barrier This is NOT a barrier I don't know Can't pay for services/medication Is this a barrier? menu Can't find providers that accept my insurance This is a barrier This is NOT a barrier I don't know Can't find providers that accept my insurance Is this a barrier? menu Lack of knowledge surrounding available services This is a barrier This is NOT a barrier I don't know Lack of knowledge surrounding available services Is this a barrier? menu Distrust of healthcare providers This is a barrier This is NOT a barrier I don't know Distrust of healthcare providers Is this a barrier? menu Not sure when I need healthcare This is a barrier This is NOT a barrier I don't know Not sure when I need healthcare Is this a barrier? menu Lack of evening and weekend services This is a barrier This is NOT a barrier I don't know Lack of evening and weekend services Is this a barrier? menu Doubt the treatments will help This is a barrier This is NOT a barrier I don't know Doubt the treatments will help Is this a barrier? menu Fear of what people will think This is a barrier This is NOT a barrier I don't know Fear of what people will think Is this a barrier? menu Afraid to have health check-up This is a barrier This is NOT a barrier I don't know Afraid to have health check-up Is this a barrier? menu Bad past experience This is a barrier This is NOT a barrier I don't know Bad past experience Is this a barrier? menu Healthcare information is not kept confidential This is a barrier This is NOT a barrier I don't know Healthcare information is not kept confidential Is this a barrier? menu Question Title * 4. How do you rate your overall health? Check one selection. Excellent Good Fair Poor Unsure Question Title * 5. How healthy would you rate your community? Very healthy Healthy Somewhat healthy Unhealthy Somewhat unhealthy Very unhealthy Question Title * 6. How is your healthcare covered? Health insurance offered from your job or a family member's job Health insurance marketplace Medicare Medicaid Military coverage I don't have health insurance Other (please specify) Question Title * 7. Who do you feel is most responsible for keeping you healthy? Check one selection. Medical professionals Hospitals School clinics Family Church or other place of worship Myself Other (please specify) Question Title * 8. Where is your first choice to go if you are sick or need advice about your health? Check one selection. Hospital emergency department The local health department A school clinic A doctor's office Nowhere - I don't have a place to go when I get sick Other (please specify) Question Title * 9. Please rate the following statements. Select only one response for each question. Your Response My community is a safe place to live. Strongly Disagree Disagree Neutral Agree Strongly Agree My community is a safe place to live. Your Response menu My community is a good place to raise children. Strongly Disagree Disagree Neutral Agree Strongly Agree My community is a good place to raise children. Your Response menu My community is a good place to grow old. Strongly Disagree Disagree Neutral Agree Strongly Agree My community is a good place to grow old. Your Response menu There is economic opportunity in my community. Strongly Disagree Disagree Neutral Agree Strongly Agree There is economic opportunity in my community. Your Response menu There are resources and support services in the community to help with special needs and in times of crisis. Strongly Disagree Disagree Neutral Agree Strongly Agree There are resources and support services in the community to help with special needs and in times of crisis. Your Response menu I voice my opinion regarding issues affecting my community when given the opportunity. Strongly Disagree Disagree Neutral Agree Strongly Agree I voice my opinion regarding issues affecting my community when given the opportunity. Your Response menu Government and community officials are responsive of the overall needs of the community. Strongly Disagree Disagree Neutral Agree Strongly Agree Government and community officials are responsive of the overall needs of the community. Your Response menu My community has affordable housing options, including rentals, government low income programs, and senior and retirement housing. Strongly Disagree Disagree Neutral Agree Strongly Agree My community has affordable housing options, including rentals, government low income programs, and senior and retirement housing. Your Response menu I regularly participate in community service activities. Strongly Disagree Disagree Neutral Agree Strongly Agree I regularly participate in community service activities. Your Response menu I am satisfied with the healthcare services I receive in my community. Strongly Disagree Disagree Neutral Agree Strongly Agree I am satisfied with the healthcare services I receive in my community. Your Response menu I am satisfied with the education opportunities in my community. Strongly Disagree Disagree Neutral Agree Strongly Agree I am satisfied with the education opportunities in my community. Your Response menu Question Title * 10. What is your age? Under 18 18-24 25-34 35-44 45-54 55-64 65+ Question Title * 11. What is your gender? Male Female Prefer not to answer Question Title * 12. Race/Ethnicity- Which group do you most identify with? White Black or African American Hispanic or Latino Asian or Asian American American Indian or Alaska Native Native Hawaiian or other Pacific Islander Another race Question Title * 13. What is your highest level of education? Grade/middle school High school diploma / GED Technical / community college 4-year college / bachelor's degree Graduate / advanced degree Question Title * 14. Employment status: Employed full-time Employed part-tme Retired Unemployed Stay at home parent / family member Student Other (please specify) Question Title * 15. Household income (before tax): Under $15,000 Between $15,000 and $29,999 Between $30,000 and $49,999 Between $50,000 and $74,999 Between $75,000 and $99,999 Over $100,000 Question Title * 16. Please list any other comments you have about health issues in your community. Question Title * 17. What county do you live in? Jones County Wayne County Smith County Jasper County Covington County Other (please specify) Question Title * 18. Please fill in the blanks for the following questions. There will be no way to identify you or your answers. Please only complete this question if you would like a copy of the final report emailed to you. Name: Address (Line 1) Address (Line 2) City: State: ZIP/Postal Code: County: Email address: Phone number: Done