New York Health Care Access Survey - Canvassing Results
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CNYH Organizer Collecting Results
Your answer
CNYH Organizer Contact (email and phone)
Your answer
Survey Number - to keep track of data, we are asking that you initial and number the surveys you are entering. Enter the Survey Number here and write it on the paper copy. Ex. Ursula Elizabeth Rozum would initial her surveys UER01, UER02 for each survey she enters into this form.)
Your answer
Date collected
MM
/
DD
/
YYYY
Do you currently have health insurance?
*
Yes
No
If you answered yes, you do have health insurance, what type?
Through my employer
Through my spouse's or parent's policy
Medicaid
Medicare
Health Insurance Marketplace
Other
What is your insurance company?
Your answer
If your insurance was purchased on the Health Insurance Marketplace, which tier did you select?
Bronze
Silver
Gold
Platinum
What’s the longest period of time you have gone without health insurance?
Your answer
Have you ever had problems getting the health care you need?
Yes
No
If yes, what were/are the reasons?
Your answer
Have you ever had to forgo needed health care because of costs?
Yes
No
If YES, what type of care?
Regular Check-Up
Surgery
Prescription Drugs
Mental Health Care
Dental Care
Vision
Diagnostic Tests
Other:
Details if applicable:
Your answer
What costs have been difficult for you (check all that apply)
Premiums
Deductibles
Co-pays
Co-insurance
Paying bills out-of-pocket
Other:
Details if applicable:
Your answer
Have you, or someone in your family, ever experienced any of the following:
Stayed in a job only to keep your health insurance?
Yes
No
If yes, please describe:
Your answer
Been discriminated against when trying to get healthcare because of your race, immigration status, gender, sexual orientation, age, or disability?
Yes
No
If yes, please describe
Your answer
Developed more serious health problems or delayed treatment because of concerns around cost?
Yes
No
If yes, please describe
Your answer
Have had problems paying medical bills?
Yes
No
If yes, please explain:
Your answer
Had trouble paying for home care?
Yes
No
If yes, please explain:
Your answer
IF the person works in a health care setting....
Do you work in a clinical setting?
Yes
No
Please describe
Your answer
Have you ever observed different treatment for patients based on health insurance status?
Yes
No
If yes, please describe
Your answer
Have you ever observed a patient delay or refuse health care because of cost?
Yes
No
If yes, please describe
Your answer
Do you feel that a patient’s concern with cost of health care has affected your relationship with the patient?
Yes
No
If yes, please describe
Your answer
CLAIMING OUR RIGHTS
Do you think we should make sure that everyone in New York can get the health care they need?
Yes
No
Do you believe that health care is a human right?
Yes
No
Do you believe our government has an obligation to protect the human right to health care?
Yes
No
Not sure
Would you say that the human right to health care is protected here in New York?
Yes
No
Not sure
Do you feel that you have a say in decisions about our health care system?
Yes
No
Responsibilities of Government: The Solution
What do you think of the idea of a universal health care system, which would be publicly funded from our taxes rather than paying premiums and deductibles to insurers and medical care providers? This type of coverage would allow for you to choose your doctor and hospital. It is often called a single-payer system or improved Medicare for All.
Like it.
Don't like it.
Not sure.
If you could change anything about our health care system, what would it be?
Your answer
Any other comments you’d like to make?
Your answer
About you (this will help us analyze the results of this survey)
The questions about gender or race are optional.
Which New York county do you live in?
Your answer
Gender
Female
Male
Transgender
Other
Your race or ethnicity
White
African American
Asian
Latino
Native/Indigenous
Other:
Your age
Your answer
Are you a medical practitioner?
Yes
No
If yes, what field?
Your answer
Do you want to get involved?
It is not necessary to give your personal information to do the survey. You can choose to remain anonymous. However, if you would like to get involved in the Campaign for New York Health, for example by telling your story, we need some way to get in touch with you!
I would like to get more involved
Yes
No
Took petitions to circulate?
Yes
No
Name
Your answer
Street Address
Your answer
City
Your answer
Zip
Your answer
Email
Your answer
Phone
Your answer
Would you like more information about the Campaign for New York Health?
Yes, please contact me about the Campaign for New York Health.
No.
What's the best way to contact you to discuss your story?
Phone
Email
Text Message
Would you be willing to allow the Campaign for New York Health to share your story in letters, press releases, or social media campaigns? (We would contact you beforehand).
Yes
No
Maybe
Thank you for completing this survey!
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