Community Health Assessment Survey

Community Health Assessment Survey

Thank you for taking a few minutes to complete the survey below. The purpose of this survey is to get your opinions about factors that impact community health in Florence County. The survey is for people who live or work in Florence County and takes about 10 minutes to complete. All answers are completely anonymous. At the end of the survey, you will have the option to follow a link to a separate form that is not in any way connected to this survey to be entered into a drawing for one of five $50 VISA gift cards. If you have any questions or concerns about this survey, contact Annette at aseibod@florencecountywi.gov or 715-528-4837. Interpreters are available upon request. Please only take this survey once.
1. In the following list, please rank the THREE most important factors for a "Healthy Community". (#1 is most important, #3 is less important)

Good place to raise childrenLow crime/safe neighborhoodsLow level of child abuseGood schoolsAccess to health care (family doctor, dentist, etc.)Parks and recreationClean environmentAffordable housingExcellent race relationsGood jobs and healthy economyStrong family lifeHealthy behaviors and lifestylesLow adult death and disease ratesLow infant deathsReligious or spiritual valuesOther
2. What kind of place do you usually go to when you are sick or need advice about your health?

A doctor's officeA clinicVA ClinicAn emergency roomAn urgent care clinicA naturopathic doctorOther
3. How do you pay for your healthcare? Check all that apply.

Health insurance (private, employee sponsored)MedicareMedicaid, Medical Assistance (MA) BadgercareVeteran's benefitsIndian or Tribal Health ServicesNo health insurance coveragePrivate pay (cash)
4. From the list below, place a check on the THREE most important health problems in your community. (those problems which have the greatest impact on overall community health)

CancerChild abuse/neglectDental problemsDiabetesDomestic violenceFire-arm related injuriesHeart disease and strokeHigh blood pressureHIV/AIDSHomicideAging problems (arthritis, hearing/vision loss, etc.)Infectious disease (hepatitis, TB, etc.)Mental health problemsMotor vehicle crash injuriesRape/sexual assaultRespiratory/Lung diseaseSexually transmitted diseaseSuicideSubstance use/abuse, including alcoholInfant deathOther
5. From the list below, place a check the THREE behaviors that have the greatest impact on overall health of the people in your community.

Alcohol abuseTobacco useDrug abuseUnsafe sexNot getting immunizations or vaccines to prevent diseasesSedentary lifestyleDropping out of schoolNot using seatbelts/child safety seatsEating unhealthy foodsOvereatingNot using birth controlNot exercisingRacismOther
6. Do you or your household have an emergency plan, including consideration to needs (home healthcare, oxygen supply, wheel chair, other special care)?
7. Does each person in your household who takes prescribed medications currently have a 7-day supply?
8. How far do you travel for health care?
9. In the event of an evacuation or having to relocate, how likely are you to attend a shelter?
10. In the last 12 months, how often have you worried that you would run out of food before you had money to buy more? choose one
11. Select the option which best describes your gender.
12. Your age group is:
13. Which of the following best describes you? (choose all that apply)

White/caucasianAfrican American/BlackAsian/Pacific IslanderNative Indigenous/American, Alaskan NativeHispanic/LatinxOther
14. Your education level is:

Less than High SchoolHigh School diploma/GEDTrade/Vocational schoolSome collegeAssociate degreeBachelor's degreeGraduate/Professional degree
15. Are you currently...

Employed (full or part-time)Self-employedUnemployed/out of workA homemaker/stay-at-home parentA studentRetiredDisabled
16. Do you speak a language other than English at home?

YesNoWhat language?
17. How many people are in your household?
Of those, how many are under the age of 18?
How many are over the age of 55?
18. What is your main source to get information about a disaster or emergency or event? (check one)

NewspaperRadioSocial media (Facebook, Instagram)Internet/Online newsTVFriends/Family/Word of mouthOther
19. Your township is...
20. What is your household income per year?

Less than $20,000$20,000-$34,999$35,000-$49,999$50,000-$74,999$75,000 or more
21. How did you get this survey? (check one)

WorkplaceMailChurchGrocery storePersonal contactCommunity meetingEmailOther
GIFT CARD ENTRY!

With your smart phone, scan the QR code below to be entered into a drawing for a $50 VISA gift card. This is completely separate and not in any way connected to your survey answers. Paper entry forms are available upon request. One entry per person. 5 winners will be selected and contacted in February 2025.

If you would like more information about this community project, please contact us at the number below.

Florence County Health Department Phone: 715-528-4837 Website: florencewipublichealth.com
Thank you very much for your participation!
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Community Health Assessment Survey

Thank you very much for your participation!