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The purpose of this survey is to get your opinions about community health issues and the quality of life in Pulaski County. In collaboration with our public health partners, the Pulaski County Commission on Children and Families will compile the responses collected and use this information to help guide our efforts to enhance the wellness of our citizens. Thank you in advance for taking a few moments to share your input with us!

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* 1. In the following list, what do you think are the three most important factors for a “Healthy Community?” (Those factors which most improve the quality of life in a community.) CHECK ONLY THREE

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* 2. In the following list, what do you think are the three most important “health problems” in our community?  (Those problems which have the greatest impact on overall community health.) CHECK ONLY THREE

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* 3. In the following list, what do you think are the three most important “risky behaviors” in our community?  (Those behaviors which have the greatest impact on overall community health.) CHECK ONLY THREE

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* 4. How would you rate the overall health of our community?

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* 5. How would you rate your own personal health?

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* 6. Approximately how many hours per month do you volunteer your time to community service?  (e.g., schools, voluntary organizations, churches, hospitals, etc.)

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* 7. Zip code where you live:

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* 8. Your age:

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* 9. Sex:

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* 10. Ethnic group you most identify with:

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* 11. Marital status:

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* 12. Education:

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* 13. Annual household income:

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* 14. How do you currently pay for your health care? CHECK ALL THAT APPLY

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* 15. Where / how did you get this survey? CHECK ONE

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* 16. Are you satisfied with the quality of life in our community? (Consider your sense of safety, well being, participation in community life and associations, etc.)

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* 17. Are you satisfied with the health care system in the community?  (Consider access, cost, availability, quality, and options in health care)

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* 18. Is this community a good place to raise children?  (Consider school quality, day care, after school programs, recreation, etc.)

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* 19. Is this community a good place to grow old?  (Consider elder-friendly housing, transportation to medical services, churches, shopping; elder day care, social support for the elderly living alone, meals on wheels, etc.)

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* 20. Is there economic opportunity in the community?  (Consider locally owned and operated businesses, jobs with career growth, job training/higher education opportunities, affordable housing, reasonable commute, etc.)

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* 21. Is the community a safe place to live?  (Consider residents’ perceptions of safety in the home, the workplace, schools, playgrounds, parks, and the mall.  Do neighbors know and trust one another?  Do they look out for one another?)

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* 22. Are there networks of support for individuals and families (neighbors, support groups, faith community outreach, agencies, organizations) during times of stress and need?

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* 23. Do all individuals and groups have the opportunity to contribute to and participate in the community’s quality of life?

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* 24. Do all residents perceive that they — individually and collectively — can make the community a better place to live?

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* 25. Are there a broad variety of health services in the community?

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* 26. Is there a sufficient number of health and social services in the community?

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* 27. Are levels of mutual trust and respect increasing among community partners as they participate in collaborative activities to achieve shared community goals?

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* 28. Is there an active sense of civic responsibility and engagement, and of civic pride in shared accomplishments?

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