ĐĎॹá>ţ˙ `bţ˙˙˙_˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙ěĽÁ[ đżč0bjbjââ N€j€jĚ,˙˙˙˙˙˙l4444444H8H\\H­I2ÄÄ(ěěěËËË,I.I.I.I.I.I.I$ßJ ˙L˘RI4ËÇËËËRI 44ěěŰgI   Ë^4ě4ě,I Ë,I Ć Ď"ŕD444řHě¸  Ü&iMWĹHČ)’G>řH4}I0­IRGŚĄMťNĄMřH HH4444ŮNorth Central Health Advisory Board Community Assessment Survey (2002) Your input is important and will be used to develop plans to improve the quality of life of our community. All information provided will be kept CONFIDENTIAL. Quality of Life Statements Rate the quality of life statements. (circle one number) Ratings are (1) = very dissatisfied, (2) = dissatisfied, (3) = satisfied, (4) = very satisfied You are satisfied with the quality of life in your community. 1 2 3 4 (Consider your sense of safety, well being, and participation in community life and associations, etc) You are satisfied with the health care system in the community. 1 2 3 4 (Consider access, cost, availability, quality, options in health care, etc.) This community is a good place to raise children. 1 2 3 4 (Consider school quality, day care, after school programs recreation, etc.) This community is a good place to grow old? 1 2 3 4 (Consider elder-friendly housing, transportation to medical services, churches, shopping, elder day care, social support for the elderly living alone, meals on wheels) There is economic opportunity in the community. 1 2 3 4 (Consider locally owned and operated businesses, jobs with career growth, job training/ higher education opportunities, affordable housing, reasonable commute, etc.) 6. The community is a safe place to live. 1 2 3 4 (Consider resident’s perceptions of safety in the home, the workplace, schools playgrounds, parks, the mall. Do neighbors know and trust one another? Do they look out for one another?) 7. You are satisfied with church and faith community outreach in the community. 1 2 3 4 Individuals and groups have the opportunity to contribute to and participate 1 2 3 4 in the community’s quality of life. 9. Residents can perceive that they can individually and can collectively make 1 2 3 4 the community a better place to live. (Consider community clean-ups, block watches, helping a neighbor) 10. You are satisfied with contribution made by businesses, agencies, and 1 2 3 4 organizations to build community assets. (Consider parks, schools, churches) 11. You are satisfied with levels of mutual trust and respect between community 1 2 3 4 partners. (Consider government, schools, churches, voluntary agencies)? 12. You are satisfied that there is a sense of community responsibility for 1 2 3 4 building community pride. Health Care Questions 1. How do you describe your health status? (circle one): good fair poor Where do you usually go when you are sick or need health care? (check all that apply) ___Doctors office ___Community Health Center ___Public Health Clinic ___Hospital Emergency Department ___Hospital Outpatient Department ___Other (Please specify):______________ In the past 12 months, was there a time when you needed health care but did not seek it? ___Yes, I needed medical care, but did not seek it. ___No, there has not been such an occasion 3a. If you answered yes to 3., what was the reason you did not seek health care?_____________________________ What do you feel are barriers to getting health care in your community? (check all that apply): ___Too much paper work ___Location of healthcare/no transportation ___Cost ___No doctor/staff speak my language ___Fear or distrust of health care system ___Other (please specifies):_____________ ___Prescription or medicine cost Where do you get information about health resources available in your community? (check all that apply) ___School ___Church ____Neighbors ___Family ___TV ___Newspaper ___Community Service Organizations (Please specify):______________________________________ ___Other (Please specify):_____________________________________________________________ 6. Do you smoke? (check one) ___Yes ____No 6a. Does someone else in the house smoke? ___Yes ___No 7. Do you drink alcohol? (check one) ___seldom ___daily ___never 8. Have you been diagnosed by a doctor with any of the following: (check all that apply): ___Diabetes ___High Blood Pressure ___Cancer ____Dental Health problems ___Stroke ___Heart Disease ___Asthma ____Lung Disease ___Sinus Problems ___Sickle Cell Anemia ___Infant death ____Obesity ___Epilepsy ___Kidney Disease ___Liver Disease ____Drug abuse/addiction ___Alcohol abuse ___Mental Disorders ___Gonorrhea ____Migraine Headaches ___Eye Disorders ___Hearing Disorders ___HIV/AIDS ____Hepatitis ___TB ___Lupus ___Arthritis ____Family Violence ___Memory Loss ___Glaucoma ___Stress ___Lack of Pregnancy Care ___Respiratory disease 9. If you or member of your household was diagnosed by a doctor with any of these diseases please answer the following questions: 9a. Cancer What type?______________________________________________ When diagnosed? ________________________________________ Does anyone in your family have or had cancer? ___Yes ___No____________(relationship) Do you or members of your household receive treatment for cancer? ___Yes ___No Has anyone in your household died from cancer? ____Yes _____When? ___No 9b. High Blood Pressure When diagnosed?_________________________________________________________ Does anyone in your family have high blood pressure ___Yes ____No __________(relationship) Do you or members of your household take medicine daily for your high blood pressure? ___Yes ___No Do you check your blood pressure daily? ___Yes ___No Has anyone in your household died from high blood pressure? ___Yes ______When ___No 9c. Diabetes (Sugar) When diagnosed?________________________________________________ Does anyone in your family have diabetes (sugar)? ___Yes ____No_____________(relationship) Do you or members of your household take medicine daily for you diabetes (sugar)? ___Yes ___No Has anyone in your household died from diabetes (sugar) ___Yes _____When? ___No 9d. Lung or Respiratory Disease When diagnosed?_____________________ What type of lung or respiratory disease? (asthma, emphysema, sinuses, bronchitis, etc)_____________________________ Does anyone in your family have lung or respiratory disease? ___Yes ___No ______________(relationship) Do you or members of your household take medicine for your lung or respiratory disease? ___Yes ___No Has anyone in your household died from lung or respiratory disease? ___Yes ____When? ___No 9e. Heart Disease When diagnosed? ________________________________ What type of heart disease? (coronary heart disease, cardiovascular disease, congestive heart failure, enlarged heart etc.) ____________________________________________________ Does anyone in your family have heart disease? ___Yes ___No ___________________(relationship) Do you or members of your household take medicine for heart disease? ___Yes ___No Has anyone in your household died from heart disease? ___Yes ____When? ____No 9f. Stroke When diagnosed?____________________________________________ Has anyone in your family had a stroke? _____Yes ____No ____________(relationship) Do you or members of your household take medicine for your stroke? ___No ___Yes Has anyone in your household died from a stroke? ___Yes ___When? ___No 9g. Homicide Has any member of your household been a victim of a homicide? ___Yes ___No Has anyone in your family been a victim of a homicide? ___Yes ___No Demographic Information 1. Male________ Female________ Age:_________ Married___ Single ___ Divorce ___ Widow ___ Race:________________________ Registered Voter: _____Yes ______No Employed:______Full-time ____Part-time ___Unemployed ___Retired ___Self-Employed Highest Education Level Attained (check one): Less than High School____ High School (9-12)_____ College Courses____ College Graduate ____ Vocational Training _____ Graduate School____ 8. Household Income: (check one) Under $10,000____ $10,000-$19,999____ $20,000-$29,999___ $30,000-$39,999____ $40,000-$50,000____ Over $51,000____ 9. How many people does this income support?____ 9a. # of children (<19) in household____# Adults____ 10. Neighborhood Group: (circle one) Argyle Park AmerCrest Woodland-Holt Oriole Heights Devon Triangle Shepherd St. Mary’s Brentnell Brittany Hills Teakwood Heights 11. How long have you been a resident? ______________Years General Environmental Issues Overall, Columbus has good environmental quality: (check one) ___strongly disagree; ___disagree; ___agree; ___strongly agree The environmental threats in North Central Columbus come from: (check all that apply) ___Industry; ___Households/Individuals; ___City Operations; ___Transportation The best way to improve the environment is to: (check all that apply) ___Pass laws; ___Provide Education; ___Charge Fines; ___Offer Incentives ___Provide Technical Assistance Ranking Environmental Issues Rank the following from low risk (1) to high risk (4). (circle one) Water Drinking Water……………………………………. 1 2 3 4 Release of untreated sewage………………………. 1 2 3 4 Flooding/drainage problems………………………. 1 2 3 4 Other_______________…………………………... 1 2 3 4 Land Weeds……………………………………………... 1 2 3 4 Vacant Lots………………………………………... 1 2 3 4 Littering/Illegal Dumping……………………….… 1 2 3 4 Abandoned Buildings……………………………... 1 2 3 4 Junk Cars……………………………………….…. 1 2 3 4 Tires……………………………………………….. 1 2 3 4 Inadequate Refuse Collection……………………… 1 2 3 4 Contaminated Land (Brownfields)………………… 1 2 3 4 Other______________…………………….……… 1 2 3 4 Air Transportation Pollution…………………………... 1 2 3 4 Industrial Air Pollution……………………………. 1 2 3 4 Smog………………………………………………. 1 2 3 4 Indoor Air Pollution……………………………….. 1 2 3 4 Cigarette/Cigar Smoke…………………………….. 1 2 3 4 Other______________…………………………..… 1 2 3 4 Other Risks Pesticide Use………………………………………. 1 2 3 4 Loss of Green Space…………………………..…… 1 2 3 4 Child Lead Exposure………………………………. 1 2 3 4 Noise Pollution………………………………….…. 1 2 3 4 Mosquitoes………………………………………… 1 2 3 4 Animal Control…………………………………..… 1 2 3 4 Rodent Control (Rats)……………………………... 1 2 3 4 Other_______________……………………….…... 1 2 3 4 Neighborhood Issues: Traffic, Sewers, and Roads Rank the following as a very low (1) need to a very high need (4). (circle one). Road Maintenance/Repair…………………….…… 1 2 3 4 Storm/Sewer Lines Maintenance and Repair……… 1 2 3 4 Traffic Mass Transportation……………………….. 1 2 3 4 Sidewalks………………………………….. 1 2 3 4 Street Lighting……………………………... 1 2 3 4 Slow Down Traffic……………………….... 1 2 3 4 Pedestrian Crosswalks……………………... 1 2 3 4 Bikeways………………………………..…. 1 2 3 4 Crime Patrols/Block Watches……………………… 1 2 3 4 Other_______________………………………….... 1 2 3 4 Thank you for your help. All information provided will be CONFIDENTIAL. 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