Allegany County Community Health Assessment

Which town/village in Allegany County do you live in?* This field is required.Full-time College Students are encouraged to complete the survey by selecting your temporary college town/village. You must live in Allegany County to complete the survey.

Alfred/Alfred Station

Allen

Alma

Almond

Amity/Belmont

Andover

Angelica

Belfast

Birdsall

Bolivar

Burns/Canaseraga

Caneadea/Houghton

Centerville

Clarksville

Cuba

Friendship

Genesee

Granger

Grove

Hume/Fillmore

Independence

New Hudson

Rushford

Scio

Ward

Wellsville

West Almond

Willing

Wirt/Richburg

Not an Allegany County Resident

Do you have health insurance?* This field is required.

YESNO

Do you have a Primary Care Provider?* This field is required.

YESNO

Have you had a cancer screening of any kind in the last 2 years?* This field is required.Some examples are: Dental screening, Lung cancer screening, colon screening to include the home kits, breast exam etc.

YESNO

Have you seen a dentist in the last year?* This field is required.(at any location, including ER visits for dental care)

YESNO

Do you have a child living in your home with a suspected or diagnosed disability/developmental delay?* This field is required.Some examples are: autism, ADHD, cystic fibrosis, diabetes, physical disability, speech delay

YESNO

In the past 12 months, has lack of transportation kept you from getting:* This field is required.Check all that apply

Medications

Groceries

To Work/ Job

To School

To Non-emergency Appointments (Doctor, Counselor, Dentist, Vision)

To Emergency Appointments (did not choose EMS due to concern of cost)

Does not apply

None of the above

Have you ever been told by a doctor or a nurse, that you had any of the following?* This field is required.Check all that apply

Diabetes

Pre-Diabetes

Heart related issues (high blood pressure, heart disease, or stroke)

Elevated cholesterol

Cancer

Overweight or Obesity

Asthma

COPD, or other breathing issues

Mental Health/depression/anxiety

None of the above

Have the lingering effects of COVID-19 ever caused anyone in your family to experience any of the following?* This field is required.Please answer each question.

In the last year, did the food you bought not last, and you had a problem buying more?* This field is required.(food purchased was not enough or didn't last)

YESNO

In the last year has the electric, gas, oil, or water company threatened to shut off services in your home?* This field is required.

YESNO

Please select your household income level:* This field is required.(gross: yearly before taxes)

$24,999 or under

$25,000 - $34,999

$35,000 - $49,999

$50,000 - $64,999

$65,000 - $99,999

$100,000+

Prefer not to answer

Have you or someone in your household had a tick bite or an illness caused by a tick in the last two years?* This field is required.Some examples are: Lyme disease, anaplasmosis

YESNO

Have you had a bat in your home or been exposed to any other wild animals in the last two years?* This field is required.Some examples are fox, skunks, racoon, opossum

YESNO

Have you had your home tested for Lead or Radon in the last two years?* This field is required.

YESNO

Have you had your private drinking water well/spring tested in the last year?* This field is required.Does not apply if you have a public drinking source

Yes

Does Not Apply, I have public water

Have you had an accidental/unintentional injury in the last 2 years where you put off getting medical attention for some reason?* This field is required.(slip, trip or fall; cut finger, head injury; farming accident; motor vehicle accident, etc.)

Yes due to lack of transportation

Yes due to lack of insurance coverage

Yes due to lack of time

Yes due to lack of priority

I have not had an accidental injury that needed medical attention

Do you practice any form of birth control or contraception?* This field is required.Some examples are: pill, shot, male or female condoms, I.U.D

Yes

Does Not Apply

Prefer not to Answer

How do you protect yourself from sexually transmitted infections?* This field is required.Some STI examples are: Syphilis, Chlamydia, Gonorrhea, Genital Warts, HPV, HIV

Not having sex (Abstinence)

Male Condom

Female Condom

Dental Dam

Monogamous Relationship (One Partner)

Prefer not to Answer

None of the above

What would help you become more physically active?* This field is required.Select All That Apply

Transportation

Groups to participate in

Safe place to walk or exercise

Workplace programs or equipment

Workshops to learn about exercise/physical activity

Free or Discounted exercise programs or gym memberships

A friend to exercise with

Activities you can do with your children

Facilities with daycare available

Already Physically Active

None of the above

Have you used any of the following Nicotine products in the past 30 days:* This field is required.Please answer each question.

Have you used any of the following THC products in the past 30 days:* This field is required.Please answer each question.

Have you participated in gambling of any kind in the last year?* This field is required.For example: lottery tickets/scratch off, online or sports betting, casinos, apps

YESNO

Have you, or anyone you know, been affected by suicide in the last year?* This field is required.(Suicide Attempt or Death by Suicide)

YESNO

Did anyone you know experience an overdose in the last 2 years?* This field is required.

YESNO

Have you had an overdose of any kind in the last 2 years?* This field is required.Some examples are: medications, narcotics, poisons, edible THC products

YESNO

What keeps you from eating more fruits and vegetables every day?* This field is required.Select All That Apply

The stores near me don't sell fresh fruits and vegetables

Too expensive

I am not sure how to cook/prepare fresh fruits and vegetables

Time it takes to prepare

I don't like to eat fruits and vegetables

I already eat fruits and veggies everyday

For you, how important are the following health priorities?Please rate each.

Please select your age range:* This field is required.Select one option.

18-24

25-34

35-44

45-54

55-64

65-74

75+

Please select your race/ethnicity:* This field is required.Select one option.

White or Caucasian

Black or African American

Hispanic or Latino

Asian or Asian American (ex: China, India, Japan, Korea, Pakistan, Philippines, etc.)

American Indian or Alaska Native

Native Hawaiian or other Pacific Islander

Other

Prefer not to answer

Please select your gender assigned at birth:* This field is required.Select one option.

Male

Female

Prefer not to answer

Other