Grand County Survey for Students

The Grand County Rural Health Network is conducting a survey of the health needs of our children and adolescents.

Our intent is to gather data to determine if children have unmet health needs. And if so, what solutions might work in our community.

The survey is anonymous. Your answers will not be linked to you in any way. Our consultants, Youth Healthcare Alliance, will analyze the data. They will present combined data to the Grand County Rural Health Network, further protecting your information.

Filling out the survey is completely voluntary.

Please share this survey with students. Any student 4th grade and older can complete the survey. 

Thank you for your time to complete the survey!

Sign in to Google to save your progress. Learn more
1. Which school district do you attend?
Clear selection
2. During the last year, have you
Yes
No
I don't know
Seen a doctor?
Seen a dentist?
Seen a mental health therapist?
Clear selection
3. During the last 12 months, have you delayed or avoided getting healthcare (like medical visits, or medicine) for you for any of the following reasons?

4. The LAST TIME you went to the doctor, the dentist, the mental health therapist, did a parent, family member, or guardian miss work to take you?

Yes
No
I don't know
The doctor
The dentist
The mental health therapist
Clear selection
5. What type of insurance do you have?
6. What are the TOP 5 health concerns you have had about you and your classmates/friends in the past year?
7.  If there was a health center on school campus, how likely are you to use it? Please answer for each type of care.

[A health center on school campus is usually a separate clinic. It is in addition to existing services provided by school health professionals (e.g. school nurses, counselors, therapists, etc.).]  
1 - Very unlikely
2 - Unlikely
3 - Neutral/unsure
4 - Likely
5 - Very likely
Medical care
Dental Care
Mental health care
Clear selection
7a. If you selected "unlikely" or "very unlikely," please share your reasons.
8. If you would go to a health center on campus, what services do you think you would use there? (Select all that apply)
[A health center on school campus is usually a separate clinic. It is in addition to existing services provided by school health professionals (e.g. school nurses, counselors, therapists, etc.).]
9. If there was community care clinic nearby, how likely are you to use it?

(A community care clinic is a clinic that offers sliding scale fees, down to $0 cost, based on income and insurance.)
1 - Very unlikely
2 - Unlikely
3 - Neutral/Unsure
4 - Likely
5 - Very Likely
Medical Care
Dental Care
Mental Health care
Clear selection
10. If there was community care clinic nearby, how likely do you think your family would be to use it?

(A community care clinic is a clinic that offers sliding scale fees, down to $0 cost, based on income and insurance.)
1 - Very Unlikely
2 - Unlikely
3 - Neutral / Unsure
4 - Likely
5 - Very Likely
Medical Care
Dental Care
Mental Health Care
Clear selection
11. Do you have any suggestions or ideas about how to improve access to care for you or your peers?
Next
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy