ࡱ> q` pbjbjqPqP R::' DDDD4DI_EEEEEFFF^^^^^^^$;`hb:^FFFFF:^EE;_GGGFREE^GF^GGJ[\b"]EE ͼDoG`]B^_0I_]BGcoGGc]Gc]FFGFFFFF:^:^oGFFFI_FFFF)DDXDz  Community Health Survey 2001/2002 Please take a moment to complete the survey below. The purpose of this survey is to get your opinions about community health problems/issues. Your Community Action Group will be provided with the results of this survey and other information to identify the most pressing problems that can be addressed through community action. If you have previously completed this survey, please dont fill out another. Your opinion is important! Thank you, and if you have any questions please contact us (see contact information on back). This survey is sponsored by Willits Action Group, Laytonville Healthy Start, Action Network in Gualala, Mendocino County Public Health Department, and the Public Health Institute. In this survey, community refers to the major area where you live, shop and get services. Please check one from the following list: Ukiah area (includes Redwood Valley,Talmage) Hopland area Potter Valley Willits area Round Valley Laytonville / Leggett area North Coast (Elk & north to Westport) South Coast (south of Elk & N.Sonoma Coast) Anderson Valley Other _________________ Please circle the number to the left of your answer. In the following list, what do you think are the three most important factors that define a Healthy Community (those factors that most affect the quality of life in a community)? Circle only three numbers: Community Involvement Low crime / safe neighborhoods Low level of child abuse Good Schools Access to health care & other services Parks and recreation Clean environment Affordable housing Tolerance for diversity Good jobs and healthy economy Strong family life Healthy behaviors and lifestyles Low death and disease rates Religious or spiritual values Arts and cultural events Other______________________ 2. In the following list, what do you think are the three most important health problems in your community? (Those problems that have the greatest impact on overall community health.) Circle only three numbers: Motor vehicle crashes Rape / sexual assault Mental health issues Homicide Child abuse / neglect Suicide Teenage pregnancy Domestic violence Firearm-related injuries Hunger Sexually Transmitted Disease (HIV,STD) Infectious Diseases (hepatitis, TB, etc.) Poor Diet / Inactivity Alcohol & other drug abuse Lack of access to health care Chronic Diseases (cancer, heart, lungs, diabetes, high blood pressure) Aging problems (e.g., arthritis, hearing/vision loss, etc.) Tobacco Use Homelessness Other_________________________ 3. How would you rate your community as a healthy community to live in? (Circle one.) 1 Very Unhealthy 2 Unhealthy 3 Somewhat Healthy 4 Healthy 5 Very Health How would you rate your own personal health? (Circle one.) 1 Very Unhealthy 2 Unhealthy 3 Somewhat Healthy 4 Healthy 5 Very Healthy 5. How would you rate your community as a safe place to grow up or to raise children? (Circle one.) 1 Very Unsafe 2 Unsafe 3 Somewhat Safe 4 Safe 5 Very Safe 6. In the following list, what do you think are the three most serious safety problems for people in your community? Circle only three numbers: Unsafe driving Alcohol and drug abuse Racism & intolerance Not using seat belts and safety seats, helmets Unsafe/unprotected sex Unsafe roads/sidewalk conditions Access to firearms by children Manufacturing of methamphetamines Growing Marijuana School violence Child abuse and neglect Domestic violence Gang-related activity Other_______________________________ How do you pay for your health care? Circle all numbers that apply: No insurance (pay cash) Health Insurance (i.e. private insurance, Blue Shield, HMO) Medi-Cal Medicare Medicare Supplemental Insurance CMSP Healthy Families Veterans Administration Indian Health Service Other___________________ 8. Within the past year, were you able to get needed healthcare? oYes oNo oNot Needed If no, please describe / explain. ______________________________________________________ ________________________________________________________________________________ 9. Have you or any one in your immediate family been living with any of the following chronic illnesses? Circle all numbers that apply: Diabetes Cancer Heart Disease Lung Disease/Asthma HIV/AIDS Alcohol or drug dependency High Blood Pressure Hepatitis Arthritis Hearing/Vision Loss 11 Other _________________________ 10. Within the past year, what type of health services did you or your immediate family members receive outside your community? Circle all numbers that apply: None Lab work CPR Training General Surgery Urology care Ear, Nose, Throat Care Podiatry Care X-Ray/MRI Hearing services Family Planning Emergency room service Immunizations General Practitioner care Mental health services Eye Care Orthopedic/Bone care Cardiac/Heart Care Dental Care Orthodontia Obstetrics/Gynecology Other_____________________________ 11. If you got health care outside your community, circle one number that best matches why: My doctor of choice is in another city. No providers for services I need. My insurance only covers doctors in another area. No appropriate doctors accept Medi-Cal/Medicaid. 12. Within the past year, what type of mental health services did you or anyone in your family need? Circle all numbers that apply: None 2 Crisis Care 3 Hospitalization 4 Counseling/Therapy 13. If you needed services, were you able to get these services in your community? oYes oNo If no, please describe / explain. __________________________________________________ ____________________________________________________________________________ Within the past year, what type of social service benefits did you or anyone in your family need? Circle all numbers that apply: None Food stamps Healthy Families insurance TANF (welfare payments) Housing assistance Medi-Cal CMSP Respite care Subsidized child care Other________________________ If you needed benefits, were you able to get them in your community? oYes oNo 15. Within the past year, have any of your family/friends needed long-term care placement (skilled nursing facility, rehab, etc.)? oYes oNo If yes, was there any difficulty obtaining placement? Please describe / explain: ________________ _______________________________________________________________________________ _______________________________________________________________________________ 16. Are you currently employed? (Circle one.) Not employed 2 Self-employed 3 Employed Part-time _____ Hours per week 4 Employed Full-time If not working, what is the main reason you are not working? (Circle one.) Ill or disabled Cannot find work Retired Taking care of family Need training Other____________________________ 18. Do you think there are enough jobs in your community for youth? oYes oNo for adults? oYes oNo 19. Does your job give you a sense of satisfaction most of the time? oYes oNo oNot Working 20. How much stress do you feel at your job on a regular basis? (Circle one.) None A little stress Some stress A lot of stress Too much stress Not Working 21. How many days in the past month were you not able to work or do your daily activities because of illness? (Circle one.) None One to several days Many days Most days Every day 22. How much of your household income do you think goes into your rent or mortgage? (Circle one.) None 2 one-third 3 one-half 4 three-fourths 23. Do you 1 rent 2 own your home 3 live with others who rent/own 4 other ? (Circle one.) 24. Are you satisfied with your housing situation? oYes oNo If no, why not? Circle all numbers that apply: too small /crowded problems with other people too run down too expensive too far from town/services other _______________________ 25. In my community, the places where I go for recreation most often are: Circle no more than three numbers: parks movie theaters live theater/dance performances/concerts social club/service club rivers/lake/beaches/woods sports fields swimming pools health/fitness clubs dance halls place for yoga, tai-chi,etc. church senior center library other_____________________________ 26. Recreation activities that I would use if the!"#5  S V |  ! 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Approximately how many hours per month do you participate in community activities such as volunteering in schools or hospitals, voluntary organizations, and churches? (Circle one.) 1 none 2 1-5 hours 3 6-10 hours 4 over 10 hours I would spend more time participating in community activities if ______________________________ ________________________________________________________________________________ Please answer the following questions about yourself so that we can see how different types of people feel about these local health issues. 28. Zip code where you live: ooooo 29. Your Gender: o Male o Female 30. Your age: Under 18 years 18 - 25 years 26 - 39 years 40 - 54 years 55 - 64 years 65 - 80 years Over 80 years 31. Ethnic group you most identify with: African American / Black Asian Hispanic / Latino Native American White / Caucasian Other__________________________ 32. Annual Household Income: Less than $20,000 $20,000 to $29,999 $30,000 to $49,999 Over $50,000 Number of people in your household: ___ 33. Your highest educational level: Less than High School graduate High School Diploma or GED College degree or higher Other_________________________ 34. Where did you get this survey? Church Community Meeting/Event Grocery Store / Shopping Mall Post Office Electronic mail Other____________________>a@aaaavbxbccc0d2dPdpddddd & F t^p@ ^ `gdq & F t^@^`gdq h^h` \ @@@^ ^de8ef[fmffff & F pgdq ^ & F ^gdq  ^  cp^ & F t^p@ ^ `gdqfffffg2gKgjgkgggggggp & F  gdq Z^Z & F  ^ `gdq & F  `gdq ^____ Thank you very much for your response! 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