Community Themes and Strengths Assessment Survey Question Title * 1. Is there a place within your community where you can buy healthy foods, such as fresh produce? Yes No I don't know OK Question Title * 2. How accessible are areas to be physically active in your community? Not accessible Somewhat accessible Moderately accessible Very accessible OK Question Title * 3. Do you think that there are enough safe places for children to play within your community? Yes No I don't know OK Question Title * 4. What do you feel is the biggest health problem in your community? (Select top 3) Poor health behaviors (Smoking, poor diet, limited exercise) Economic challenges (unemployment, poverty, education levels) Limited access to health care Drug and/or alcohol abuse Health of babies, mothers, and children (teen pregnancy, childhood obesity, prenatal care) Chronic illness (diabetes, cancer, obesity, ongoing pain) Depression, anxiety, stress, people feeling judged for seeking mental health treatment Low community involvement, hopelessness, apathy Injury and violence Health/safety of indoor and outdoor spaces Comments: OK Question Title * 5. How difficult is it to receive the following services within your community? Very difficult Somewhat difficult Not at all difficult I don't know Mental health Mental health Very difficult Mental health Somewhat difficult Mental health Not at all difficult Mental health I don't know Addiction services Addiction services Very difficult Addiction services Somewhat difficult Addiction services Not at all difficult Addiction services I don't know Primary care (general care) Primary care (general care) Very difficult Primary care (general care) Somewhat difficult Primary care (general care) Not at all difficult Primary care (general care) I don't know Specialty care (cardiologist, podiatrist, etc.) Specialty care (cardiologist, podiatrist, etc.) Very difficult Specialty care (cardiologist, podiatrist, etc.) Somewhat difficult Specialty care (cardiologist, podiatrist, etc.) Not at all difficult Specialty care (cardiologist, podiatrist, etc.) I don't know Dental care Dental care Very difficult Dental care Somewhat difficult Dental care Not at all difficult Dental care I don't know Comments: OK Question Title * 6. Some people choose not to seek help for mental health issues. What do you think is the primary reason people in your community might avoid getting help for mental health issues? (Select ONE) The treatment is not available or is too far away The cost of treatment is too high People worry that others will find out about the issue and/or treatment Most people who need treatment do not believe they have a problem People don't know how or where to get this type of treatment Comments: OK Question Title * 7. If you were seriously injured, how long would it take you to get to a hospital, urgent care, or emergency room for treatment? 5 minutes or less 10 minutes 20 minutes 40 minutes or longer OK Question Title * 8. Do you consider yourself hopeful? Yes No I don't know OK Question Title * 9. Do you have someone that you consider your regular healthcare provider? Yes No I don't know Comments: OK Question Title * 10. Please indicate if any of the following issues prevented you from accessing health care in the past year (please select all that apply): The doctor's office wasn't accepting your health insurance The doctor's office wasn't accepting new patients You were unable to find transportation You were unable to afford transportation You were unable to take or afford time off from work You were unable to find necessary childcare The service you needed was too far to access The cost was too high (insurance deductible, co-pay, lab costs, prescriptions) Accessing health services was not an issue for me in the past year Other (please specify) OK Question Title * 11. Please let us know if you or someone in your family were unable to do any of the following within the last year due to the inability to afford the service (please select all that apply): Fill a prescription Access primary care Access specialty care Access dental care Access mental health care Access substance abuse services Cost was not a barrier to care for me or my family in the past year OK Question Title * 12. What county do you live in? Athens Gallia Meigs Jackson Vinton Other (please specify) OK Question Title * 13. What is your zip code? OK Question Title * 14. Please tell us your age: Under 18 18-24 25-44 45-64 65+ OK Question Title * 15. Please tell us your sex: Male Female OK Question Title * 16. What is your marital status? Single, never married Married/domestic partnership Widowed/Widower Divorced OK Question Title * 17. What is your average yearly household income? Under $10,000 Between $10,000 and $19,999 Between $20,000 and $29,999 Between $30,000 and $39,999 Between $40,000 and $49,999 Between $50,000 and $59,999 Between $60,000 and $74,999 Between $75,000 and $99,999 Between $100,000 and $149,999 Between $150,000 and $199,999 $200,000 or more OK Question Title * 18. What is your highest level of education? Less than high school High school diploma/GED Some college Associate degree Bachelor's degree Master's degree or higher OK Question Title * 19. What is your current insurance status? Insurance plan through an employer Self-purchased insurance plan Medicare/Medicaid/Other government program Uninsured I don't know OK DONE