2019 Community Health Needs Assessment
Sheridan Memorial Hospital Association in Plentywood, Montana is conducting a Community Health Needs Assessment (CHNA) survey to better understand the health concerns and needs in the community. The information obtained from the CHNA will be used in the development of an action plan to help improve the health of local community members. Please note that all questions are optional and confidential.

Please only complete this survey once and only if you are a resident of Sheridan County, Montana.
Thank you for your participation.

What is a CHNA and why are we doing it?

The Patient Protection and Affordable Care Act, signed into law Mar. 23, 2010, requires hospitals with a
501(c)(3) tax-exempt status, that's Sheridan Memorial Hospital Association, to meet requirements to
comply with the intent of a charitable hospital. The CHNA must be conducted every three years and
incorporate input from “persons who represent the broad interests of the community served by the
hospital, including those with special knowledge of, or expertise in public health." This report provides
guidance for the operational implementation of the community health needs assessment and subsequent
community-based health improvement plans.
PLEASE NOTE: All information is confidential - there is nothing that will indicate to us who filled out this
form UNLESS you provide your information at the end of the survey.
Please only complete this survey once and only if you are a resident of Sheridan County, Montana.


1. How would you describe your overall health?
2. What are the biggest health issues or concerns in your community? (check all that apply)
3. What keeps you or others in your community from seeking medical treatment? (Check all that apply)
4.What is needed to improve the health of your family and neighbors? (Check all that apply)
5. What health screenings or education/information services are needed in your community?(Check all that apply)
6. If you or someone in your family were ill and required medical care, where would you go?(Check one)
7. Where do you and your family get most of your health information? (Check all that apply)
8. Where do you turn to get general information about the community (i.e. business hours,services offered, announcements, etc.)
9. What additional health services would help meet health challenges in your community?
Your answer
10. When seeking care, which hospital would you visit FIRST? (Check one)
11. Please choose all statements below that apply to you.
12. Which of the following preventive procedures have you had in the past 12 months?
13. Have you had a routine physical exam (annual Wellness exam) in the past two years?
14. In what ZIP code is your home located?
15. What is your gender?
16. Which category below includes your age?
17. What is your racial/ethnic identification?
18. Do you have health insurance?
19. Do you need a Primary Care Provider? (Family Practice). If so, please provide your contact information below. First/Last Name, Mailing Address, City, State Zip
Your answer
20. Would you like to receive information about free or low-cost health coverage options? If so,please provide your contact information below. First/Last Name, Mailing Address, City, State Zip
Your answer
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service