Social Determinants of Health

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This survey is to help us pinpoint areas where community members may be struggling to get their needs met.

FINANCIAL STRAIN:

How hard is it for you, or a family member who lives in your home to pay for the very basics like food, housing, medical care and heating? Would you say it is:

Very Hard

Somewhat Hard

Not Hard at All

UTILITIES:

In the past 12 months has the electric, gas, oil, or water company threatened to shut off services in your home?

Yes

Already Shut Off

TRANSPORTATION:

In the past 12 months, has lack of reliable transportation kept you or a family member who lives in your home from getting to medical appointments, meetings, work or from getting things needed for daily living?

Yes

FOOD:

Within the past 12 months, have you or someone in your home worried that your food would run out before you got money to buy more.

Often True

Sometimes True

Never True

FOOD:

Within the past 12 months, the food you bought just didn't last and you didn't have money to get more.

Often True

Sometimes True

Never True

LIVING SITUATION:

What is your living situation today?

I have a steady place to live

I have a place to live today, but I AM WORRIED about losing it in the future.

I do not have a steady place to live (I am temporarily staying with others, in a hotel, in a shelter, living outside on the street, on a beach, in a car, abandoned building, bus or train station, or in a park)

LIVING SITUATION:

Think about the place you live. Do you have problems with any of the following? CHOOSE ALL THAT APPLY

Pests (bed bugs, roaches, ants, mice, etc.)

Mold

Lead paint

Lack of heat

Appliances not working (ex: stove, oven, refrigerator, etc.)

Smoke Detectors missing or not working

Water leaks

Not hot water

Other:

Required

If you would like someone to contact you, please leave your name and a way to reach you (phone number, email address, etc.)

If you would, please provide us your Zip Code

If you would like to respond, please provide us an estimate of your annual income:

0 - $15,000

$16,000 - $30000

$31000 - $45000

$45000 - $60000

$60000 and above

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