Tri-Community Coalition Assessment Survey
What is your age?
What is your gender?
Please specify the category that best describes you.
Please state the zip code area you currently reside in:
Your answer
How would you define your personal health?
How would you rate your stress level during the past week?
Not stressed at all
Extremely stressed
How would you rate your stress level during the past 30 days?
Not stressed at all
Extremely stressed
Are you aware of methods to help decrease your stress level?
In the past 30 days, how often have you felt down, depressed, or hopeless?
In the past 30 days, were you able to find helpful resources to deal with feeling down, depressed, or hopeless?
What health services are available in your community? Please check all that apply.
How satisfied are you with the current health care services offered in your community?
Do you feel like you have support in your community to help you during stressful times?
Do you feel your community is a safe place to live?
What are some barriers that exist in your community that interfere with your healthy living?
Your answer
What are the three biggest problems facing your community?
Your answer
How involved are you with the youth in your community?
How aware are you of youth-related health issues in your community?
Do you agree that the community has an impact on health outcomes for youth?
Have you used any of the following substances in the past 30 days?
How harmful do you feel each of the following substances are to your health?
Extremely Harmful
Very Harmful
Somewhat Harmful
Not Harmful
It Depends on How Often it is Used
How do you feel about the possibility of marijuana becoming legalized in your area?
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