Senior Community Health Assessment Survey

お使いのブラウザで JavaScript が有効になっていないため、このファイルは開けません。有効にして再読み込みしてください。

This survey was created by the Leicester Regional Public Health Coalition which is working in conjunction with the Boards of Health of the area towns, including the Holden Board of Health, to develop a comprehensive Community Health Improvement Plan. We are asking the senior citizens of Holden questions about the town/community they live in.

Please DO NOT write your name on this survey. All answers are COMPLETELY CONFIDENTIAL, so please be sure to answer all questions truthfully. If you are not comfortable answering a question you may leave it blank.

Thank you for doing your part in making the community a better place!

Google にログインすると作業内容を保存できます。詳細

What is your sex?

Male

Female

選択を解除

Some people describe themselves as transgender when their sex at birth does not match the way they think or feel about their gender. Are you transgender?

Yes

I am unsure

選択を解除

What is your race?

American Indian or Alaskan

Asian

Black or African American

Native Hawaiian or Other Pacific Islander

White

Hispanic or Latino

Multi Racial

選択を解除

Which of the following concerns do you think are most urgent in your community?

Access to Affordable Housing

Access to Food

Access to Quality and Affordable Health Care

Access to Quality and Affordable Mental Health Care/Resources

Alcohol/Drug Use

Automobile Safety

Chronic Disease Prevention (Diabetes, Heart Disease, Obesity, etc...)

Communicable Disease Prevention (able to spread from person to person)

Computer Literacy

Education System

Homelessness

Infectious Disease Prevention (caused by infection)

Lack of Community Parks/Pools/Beaches/Walking Paths

Need of Resources for Education About Common Scams

Need of Resources for Help With Yard Work and/or Household Tasks

Personal Safety

Poverty

Public Transportation

Smoking/Tobacco Use/Vaping

Violence (Dating, Domestic, Gang, etc...)

その他:

If you selected "Other," please explain.

What programs/initiatives would you like to see implemented to help with the community concerns you identified?

To what level do you agree with the following statement: I feel accepted amongst my peers regardless of my sex, race, religion, primary language spoken, etc...?

Strongly disagree

Disagree

Neutral

Agree

Strongly agree

選択を解除

送信

フォームをクリア

Google フォームでパスワードを送信しないでください。

このコンテンツは Google が作成または承認したものではありません。不正行為の報告 - 利用規約 - プライバシーポリシー

フォーム