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Franklin Co. CHA- Community Survey

1. What is your age range? *This question is required.

2. What is your gender? *This question is required.

3. What is your race or ethnicity? You can select more than one.

Please enter an 'other' value for this selection.

4. What is the highest level of school you have completed?

5. What is your zip code? *This question is required.

6. Which of the following categories best describes your household income? *This question is required.

7. How would you rate the overall health of your community?

For each issue listed below, select the option that best describes it:

☐ Not a problem ☐ A minor problem ☐ A major problem

*This question is required.

Space Cell	Not a Problem	Minor Problem	Major Problem
Access to healthcare	Access to healthcare : Not a Problem	Access to healthcare : Minor Problem	Access to healthcare : Major Problem
Chronic disease (Diabetes, Heart Disease, Kidney disease, etc.)	Chronic disease (Diabetes, Heart Disease, Kidney disease, etc.): Not a Problem	Chronic disease (Diabetes, Heart Disease, Kidney disease, etc.): Minor Problem	Chronic disease (Diabetes, Heart Disease, Kidney disease, etc.): Major Problem
Cancer	Cancer: Not a Problem	Cancer: Minor Problem	Cancer: Major Problem
Immunizations	Immunizations: Not a Problem	Immunizations: Minor Problem	Immunizations: Major Problem
Mental or behavioral health care	Mental or behavioral health care : Not a Problem	Mental or behavioral health care : Minor Problem	Mental or behavioral health care : Major Problem
Obesity	Obesity : Not a Problem	Obesity : Minor Problem	Obesity : Major Problem
Infant mortality	Infant mortality : Not a Problem	Infant mortality : Minor Problem	Infant mortality : Major Problem
Suicide	Suicide : Not a Problem	Suicide : Minor Problem	Suicide : Major Problem
Youth tobacco use and vaping	Youth tobacco use and vaping : Not a Problem	Youth tobacco use and vaping : Minor Problem	Youth tobacco use and vaping : Major Problem
Adult tobacco use and vaping	Adult tobacco use and vaping : Not a Problem	Adult tobacco use and vaping : Minor Problem	Adult tobacco use and vaping : Major Problem
Substance use - drugs or alcohol	Substance use - drugs or alcohol : Not a Problem	Substance use - drugs or alcohol : Minor Problem	Substance use - drugs or alcohol : Major Problem
Lack of physical activity	Lack of physical activity: Not a Problem	Lack of physical activity: Minor Problem	Lack of physical activity: Major Problem
Lack of access to parks, trails, and sidewalks	Lack of access to parks, trails, and sidewalks: Not a Problem	Lack of access to parks, trails, and sidewalks: Minor Problem	Lack of access to parks, trails, and sidewalks: Major Problem
Poverty	Poverty: Not a Problem	Poverty: Minor Problem	Poverty: Major Problem
Domestic violence	Domestic violence : Not a Problem	Domestic violence : Minor Problem	Domestic violence : Major Problem
Education	Education : Not a Problem	Education : Minor Problem	Education : Major Problem
Physical or cyber bullying	Physical or cyber bullying : Not a Problem	Physical or cyber bullying : Minor Problem	Physical or cyber bullying : Major Problem
Access to jobs providing living wage	Access to jobs providing living wage : Not a Problem	Access to jobs providing living wage : Minor Problem	Access to jobs providing living wage : Major Problem
Gun violence	Gun violence : Not a Problem	Gun violence : Minor Problem	Gun violence : Major Problem
Access to healthy food	Access to healthy food : Not a Problem	Access to healthy food : Minor Problem	Access to healthy food : Major Problem
Mobile food distributions	Mobile food distributions: Not a Problem	Mobile food distributions: Minor Problem	Mobile food distributions: Major Problem
Access to services for children with disabilities or special needs	Access to services for children with disabilities or special needs : Not a Problem	Access to services for children with disabilities or special needs : Minor Problem	Access to services for children with disabilities or special needs : Major Problem
Access to services for adults with disabilities or special needs	Access to services for adults with disabilities or special needs : Not a Problem	Access to services for adults with disabilities or special needs : Minor Problem	Access to services for adults with disabilities or special needs : Major Problem
Affordable health insurance	Affordable health insurance : Not a Problem	Affordable health insurance : Minor Problem	Affordable health insurance : Major Problem
Access to reliable/affordable transportation	Access to reliable/affordable transportation : Not a Problem	Access to reliable/affordable transportation : Minor Problem	Access to reliable/affordable transportation : Major Problem
Teen pregnancy	Teen pregnancy: Not a Problem	Teen pregnancy: Minor Problem	Teen pregnancy: Major Problem
Child abuse or neglect	Child abuse or neglect: Not a Problem	Child abuse or neglect: Minor Problem	Child abuse or neglect: Major Problem
Understanding healthcare/health literacy	Understanding healthcare/health literacy: Not a Problem	Understanding healthcare/health literacy: Minor Problem	Understanding healthcare/health literacy: Major Problem
Training Opportunities for adult caregivers	Training Opportunities for adult caregivers : Not a Problem	Training Opportunities for adult caregivers : Minor Problem	Training Opportunities for adult caregivers : Major Problem
loneliness or isolation	loneliness or isolation: Not a Problem	loneliness or isolation: Minor Problem	loneliness or isolation: Major Problem
Homelessness	Homelessness : Not a Problem	Homelessness : Minor Problem	Homelessness : Major Problem
Other:	Other: : Not a Problem	Other: : Minor Problem	Other: : Major Problem
Enter another option	Other: Not a Problem	Other: Minor Problem	Other: Major Problem
Enter another option	Other: Not a Problem	Other: Minor Problem	Other: Major Problem

9. How well does your community support the needs of older adults? *This question is required.

Well	Very well	Not at all
Well	Very well	Not at all

10. What could the community do differently to support the needs of older adults?