WHAT DO YOU THINK?

The Department of Health in Indian River would like to identify the needs of communities within the county. Your input is important because it is the basis for assessing which environmental health problems exist in your community. Please assist us by completing this survey and returning it to the Health Department or Dasie Hope Center. Questions? Contact Molly or Julianne at 772-794-7410. Thank you for your participation!

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* 1. Where do you live?

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* 2. What is your zip code?

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* 3. How many people currently live in your household?

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* 4. What is your age?

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* 5. How many of the members of your household are under the age of 18?

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* 6. Does your community need assistance and/or information on the following? (mark all that apply)

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* 7. In the past month did you or other adults in your household ever cut the size of your meals or skip meals because there wasn't enough money for food?

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* 8. Are you usually able to get the food that you want to eat?

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* 9. If you answered "no" to the question above, what prevents you from getting the food you want to eat?

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* 10. How many days in the past month did poor physical health interfere with daily activities?'

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* 11. How many days in the past month did poor mental health interfere with daily activities?

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* 12. Are you aware of Community Supported Agriculture (CSA) or a food co-op in our county?

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* 13. In the past month, how often have you or someone in your household used each of the following sources  to get food?

  Never Once  A few times Often
 Grocery Store 
Convenience store, carryout or corner store (eg., gas station, pharmacy, discount store)
Fast Food Restaurant (i.e., has many locations and, often, a drive-through window)
Sit-in Restaurant (i.e., has wait staff)
Food Pantry
Free Meal (e.g., Senior Center, church meal)
Farmers’ Market or Produce Stand (when in season)
Your own garden (when in season)

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* 14. Please rate how important the following are  in your decision about what food to buy

  Not important Important Very Important
Taste
Nutritional value
Appearance
Price
Locally grown
Organically grown or grown without the use of pesticides

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* 15. In your neighborhood is there one of the following?

  Yes No Yes but needs improvement
Sidewalks or walking / biking paths
Parks or playgrounds
Recreation or community center
Fresh foods / market
Public transportation / bus stops

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* 16. What would make it easier for you to consume more fruits, vegetables and lean proteins?   Please check the items that would make it easier.

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