Kentucky River Foothills-Community Needs Assessment

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The following questionnaire will only take a few minutes to complete and it will assist in helping people and meeting the community needs. All information will be kept confidential and your name is not required on the questionnaire. THANK YOU FOR YOUR TIME!

1. In which county do you live or represent (for the agency)? *

Clark County, KY

Estill County, KY

Madison County, KY

Powell County, KY

2. What is your age?

Under 18

18-30

31-40

41-50

51-65

65+

Clear selection

3. What is your race?

American Indian or Alaskan Native

Asian

Black or African American

Native Hawaiian or Other Pacific Islander

White

Multi-racial

Other:

Clear selection

Are you Hispanic or Latino?

Yes

Rather not answer

Clear selection

What is your total annual household income (pre-tax)?

Less than $20,000

$20,000 to $34,999

$35,000 to $49,999

$50,000 to $74, 999

$75,000 to $99,999

Over $100,000

Clear selection

4. What is your education level?

Grades 0-8

Grade 9-12 Non-Graduate

High School Graduate or Equivalent

Some college

2 or 4 Years College Graduate

Post Graduate or Other Post Secondary Degree

Clear selection

Do you see any medical providers at Kentucky River Foothills' Health and Wellness Center or mobile unit? (LCSW, Nurse Practitioner, or Doctor)

Yes

Clear selection

What is your Military Status

Veteran

Active Military

N/A

Clear selection

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