Community Health Needs Assessment
1.
When you think about the place you live, what are you most concerned about?
Affordable housing
affordable healthcare
livable wage
economic opportunities
clean environment
affordable and healthy food choices
transportation
crime/vandalism
drug and alcohol abuse
Other (please specify)
2.
When you imagine a strong, vibrant, healthy community, what are the most important features you think of? Please choose three.
good schools
safe environment
health care services
livable wages
affordable housing
economic opportunities
walkable and bike friendly communities
parks and recreation
Other (please specify)
3.
Healthcare- in your community, how much need is there for (choose top three priorities)...
access to primary care providers
access to dental care
affordable health care
short term community support after hospitalization
affordable dental care
access to specialty care
access to alternative health care providers (acupuncture,chiropractic,etc)
4.
Mental health- in your community, how much need is there for (choose top three priorities)
more mental health providers
timely access to treatment
early detection of mental health issues for children/teens
prevention of mental health issues
access to mental health services for children/teens
access to residential treatment
Other (please specify)
5.
Substance Use- In your community, how much need is there for…(choose three)
Substance use prevention programs
access to outpatient treatment
access to inpatient treatment
strict controls on opiates and narcotic prescriptions
reduction in binge drinking
reduction in marijuana use
increase access to medication assisted treatment
Other (please specify)
6.
Seniors- in your community, how much need is there for (choose top three priorities)
Social support organizations/agencies
elder care
elder housing
transportation
affordable in home care
access to long term health care
access to nursing home care
Other (please specify)
7.
Children and families- in your community, how much need is there for (choose top three)
afterschool programming
mentoring programs
parenting education
support for families
more childcare options, good schools
home visit programs for babies/new parents
parent/child resource centers
Other (please specify)
8.
Hunger and nutrition- in your community, how much need is there for (choose top three)
access to affordable healthy foods
knowledge of how to prepare health food
obesity prevention programs, adequate nutrition for children
adequate nutrition for seniors, more access to health foods in schools
Other (please specify)
9.
Housing- in your community, how much need is there for (top three)
affordable housing
high quality housing
housing for those with criminal backgrounds
housing for those with poor credit
sober housing
housing for individuals with mental illness
safe neighborhoods
10.
What keeps people in your community from getting medical care? (check all that apply)
lack of insurance
copay/deductibles are too high
services are too far away
don't have transportation to get to medical appointments
lack of providers
limited access to primary care providers
limited access to specialty care
language barriers
no barriers
Other (please specify)
11.
What is needed to improve the health of your family and neighbors? (check all that apply)
healthier food
job opportunities
mental health services
substance use treatment services
transportation
specialty care
safe places to play/walk
I don't know
Other (please specify)
12.
What is your gender?
male
female
Other (please specify)
13.
What is your zip code?
14.
How old are you?
Under 18
18-29
30-39
40-49
50-59
60-69
70-79
80 or older
15.
Ethnicity
Hispanic or Latino or Spanish Origin
Not Hispanic or Latino or Spanish Origin
16.
Race
American Indian or Alaskan Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
17.
What is your highest level of education?
K-8 grade
Some high school
High School grad
Technical school
Some college
College graduate
Graduate school
Doctorate
Other (please specify)
18.
Do you have health insurance?
No insurance
Yes- employer provided
Yes- Medicaid/ Apple Health
Yes- Medicare
Yes- purchase private insurance on own
Yes- purchase private insurance through the health exchange