Holden Public Community Health Assessment Survey

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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 residents of Holden 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!

How old are you?

18 years or younger

19 - 30 years old

31 - 50 years old

51 years or older

Clear selection

What is your sex?

Male

Female

Clear selection

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

Clear selection

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

Clear selection

Please place an X next to which of the following concerns you think are greatest in your town/community? (Select All That Apply)

Access to Food

Access to Quality Health Care

Access to Quality Mental Health Care/Resources

Affordable Housing

Alcohol/Drug Use

Automobile Safety

Bullying (cyber and/or physical)

Chronic Disease Prevention (diabetes, heart disease, obesity, etc...)

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

Dating Violence

Domestic Violence

Gang Violence

Homelessness

Lack of Community Parks

Poor Educational System

Poor Overall Mental Health

Poverty

Public Transportation

Racism

Sexism

Smoking/Tobacco Use/Vaping

Violence (At School)

Other:

If you selected "Other," please explain.

What types of services would you like to see implemented in your community to help with these concerns?

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

Clear selection

Additional space for comments/questions

Submit

Clear form

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