Community Health Survey (example)

Please take a minute to complete the survey below.  The purpose of this survey is to get your opinions about community health problems in (name of jurisdiction).  The (name of jurisdiction) Community Health Committee will use the results of this survey and other information to identify the most pressing problems which can be addressed through community action.  Remember… your opinion is important!  Thank you and if you have any questions, please contact us (see contact information on back).

1.     In the following list, what do you think are the three most important factors for a healthy community?  Select those factors which you feel most improve the quality of life in a community.

Check only three:

___  Good place to raise children ___  Low crime / safe neighborhoods ___  Low level of child abuse ___  Good schools ___  Access to health care (e.g., family doctor) ___  Parks and recreation ___  Clean environment ___  Affordable housing ___  Arts and cultural events

___  Excellent race relations ___  Good jobs and healthy economy ___  Strong family life ___  Healthy behaviors and lifestyles ___  Low adult death and disease rates ___  Low infant deaths ___  Religious or spiritual values ___  Other___________________________

2.     In the following list, what do you think are the three most important health problems in our community?  Select the top three problems which you feel have the greatest impact on overall community health.

___ Aging problems (e.g., arthritis, hearing/vision loss, etc.) ___  Cancers ___  Child abuse / neglect ___  Dental problems ___  Diabetes ___  Domestic Violence ___ Firearm-related injuries

___  Heart disease and stroke ___  High blood pressure ___  HIV / AIDS ___  Homicide ___  Infant Death ___  Infectious Diseases (e.g., hepatitis, TB, etc.) ___  Mental health problems ___  Motor vehicle crash injuries

___  Rape / sexual assault ___  Respiratory / lung disease ___  Sexually Transmitted Diseases (STDs) ___  Suicide ___  Teenage pregnancy ___  Other ___________________

3.  In the following list, what do you think are the three most important risky behaviors in our community?  Select the three behaviors which you feel have the greatest impact on overall community health.

___  Alcohol abuse ___  Being overweight   ___  Dropping out of school ___  Drug abuse ___  Lack of exercise ___  Poor eating habits ___  Not getting “shots” to prevent disease

___  Racism ___  Tobacco use ___  Not using birth control ___  Not using seat belts / child safety seats ___  Unsafe sex ___  Other___________________________

4.  How would rate our community as a Healthy Community?

___  Very unhealthy     ___  Unhealthy      ___  Somewhat healthy   ___  Healthy           ___  Very healthy

5.  How would rate your own personal health?

___  Very unhealthy     ___  Unhealthy      ___  Somewhat healthy   ___  Healthy           ___  Very healthy

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

___  None             ___ 1 - 5 hours                     ___  6 - 10 hours                                  ___  Over 10 hours

Please answer questions #7-15 so we can see how different types of people feel about local health issues.

7.  Zip code where you live: ____________

8.  Age:                    ___  25 or less

                                ___  26 - 39

                                ___  40 - 54

                                ___  55 - 64

                                ___  65 or over

9.  Sex: ___  Male              ___  Female

10.  Ethnic group you most identify with:

                ___  African American / Black

                ___  Asian / Pacific Islander

                ___  Hispanic / Latino

                ___  Native American

                ___  White / Caucasian

                ___  Other _________________

11.  Marital Status:

                ___  Married / co-habitating

                ___  Not married / Single

12.  Education

                ___  Less than high school

                ___  High school diploma or GED

                ___  College degree or higher

                ___  Other__________________

13.  Household income

                ___  Less than $20,000

                ___  $20,000 to $29,999

                ___  $30,000 to $49,999

                ___  Over $50,000

14.    How do you pay for your health care? (check all that apply)

                ___  Pay cash (no insurance)

                ___  Health insurance (e.g., private            

                      insurance, Blue Shield, HMO)

                ___  Medicaid

                ___  Medicare

                ___  Veterans’ Administration

                ___  Indian Health Services

                ___  Other ____________________

15.  Where / how you got this survey:  (check one)

                ___  Church

                ___  Community Meeting

                ___  Grocery Store / Shopping Mall

                ___  Mail

                ___  Newspaper

                ___  Newsletter

                ___  Personal Contact

                ___  Workplace

                ___  Other ____________________