UMI Community Imaging Clinic Social Needs Screening Survey

As a free nonprofit clinic, UMI Community Imaging Clinic is committed to serving its community and to contribute to larger research for the purpose of advancing care and services for the disadvantaged members of our society. We thank you for completing this survey that helps us better identify the needs of communities we serve. The information you provide in this survey is strictly confidential.

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HOUSING 1: Are you worried or concerned that in the next two months you may not have stable housing that you own, rent, or stay in as a part of a household?  
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HOUSING 2: Think about the place you live. Do you have problems with any of the following? (check all that apply)  
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Required
  FOOD  
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Often True
Sometimes True
Never True
Within the past 12 months, you worried that your food would run out before you got money to buy more.
Within the past 12 months, the food you bought just didn’t last and you didn’t have money to get more.
TRANSPORTATION: Do you put off or neglect going to the doctor because of distance or transportation?  
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UTILITY: In the past 12 months has the electric, gas, oil, or water company threatened to shut off services in your home?  
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CHILDCARE: Do problems getting child care make it difficult for you to work or study?  
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EMPLOYMENT: Do you have a job?  
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EDUCATION: Do you have a high school degree?  
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FINANCES: How often does this describe you? I don’t have enough money to pay my bills:  
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PERSONAL SAFETY  
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Never
Rarely
Sometimes
Fairly Often
Frequently
How often does anyone, including family, physically hurt you?
How often does anyone, including family, insult or talk down to you?
How often does anyone, including family, threaten you with harm?
How often does anyone, including family, scream or curse at you?
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