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Public Survey - Reaching Rural Surgical Seniors - National Grange Campaign
This survey is concerning the National Grange Reaching Rural Surgical Seniors Campaign. The survey takes approximately 9 minutes to complete. Please answer the following questions by checking the appropriate box.
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This program was funded through a Patient-Centered Outcomes Research Institute (PCORI) Eugene Washington PCORI Engagement Award (EADI #30051)
Age
15-35
36-50
51-75
75 - UP
Which describes the person filling out this survey?
Self/Patient/Individual
Family Member
Care Giver
Other:
Clear selection
Please mark any vaccinations received since September 2023
COVID-19
Flu
Other
How would you describe your living environment?
Rural
Suburban
Urban
Do you live alone or have a resident support person?
Live Alone
Living at home with a family support person - spouse, children, partner, family member
Living at home with a professional health aid, care giver
Live in a facility (assisted living, nursing home) with 24/7 health services
How far is it to the nearest medical care facility (urgent care, hospital)?
1-20 Miles
21-40 Miles
41-60 Miles
61-More Miles
Clear selection
What type of internet access do you have at home?
Broadband
Dial-up
Only have access to the internet on my cell phone
Do not have access to the internet
Have access only at a public facility (library, store)
Do not know
Clear selection
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