Little Falls Medical Group Survey

Little Falls Medical Group Survey

Health Equity Impact Assessment
Section 1: MVHS Little Falls Medical Group

Respond to the following questions based on your experience with MVHS Little Falls Medical Group in the past 12 months.
How many times have you visited the MVHS Little falls office in the past 12 months: *
# of visits
Personal CarCarpool or Family Member/FriendRideshare Services (Lyft, Uber, Taxi, etc.)Public Transportation (Bus, Train, Shuttle, etc.)Non-Emergency Transportation (Medicaid Shuttle)Other
012345678910
Please share any experience(s) with MVHS Little Falls Medical Group that informs your rating?
Strongly DisagreeDisagreeNeutralAgreeStrongly AgreeN/A, Prefer not to answer
Strongly DisagreeDisagreeNeutralAgreeStrongly AgreeN/A, Prefer not to answer
Strongly DisagreeDisagreeNeutralAgreeStrongly AgreeN/A, Prefer not to answer
Section 2: Little Falls Relocation

Respond to the following questions to help us understand the potential impact and benefits of relocating MVHS’s Little Falls Medical Group to 159 W. Main Street, Little Falls, NY?
YesNo
YesNo
YesNo
Are there existing services you’d like to see improved at the new MVHS Little Falls Medical Group location?
Strongly DisagreeDisagreeNeutralAgreeStrongly AgreeN/A, Prefer not to answer
Which additional programs or services would you like to see at Little Falls:
OPTIONAL DEMOGRAPHIC DISCLOSURE
Please share your ZIP code:*
Under 1818 to 2425 to 3435 to 4445 to 5455 to 6465 to 7475 or olderPrefer not to answer
ManWomanGender non-conformingPrefer not to answerI would prefer to self-identify
American Indian or Alaska NativeAsian or Asian AmericanBlack or African AmericanHispanic, Latino, Latina, or LatinxMiddle Eastern or North AfricanNative Hawaiian or other Pacific IslanderWhiteI prefer not to answer this questionAnother option not listed here (please specify):
Employed full-timeEmployed part-timeRetiredUnemployedDisabledStudentPrefer not to answerOther (please specify)
Less than $25,000$25,000-$49,999$50,000-$74,999$75,000-$99,999$100,000-$124,999$125,000-$149,999$150,000-$199,999$200,000 or morePrefer not to answer
We're sorry, this survey is only for patients over the age of 18. Thank you for your time, your survey results will not be recorded.
Should be Empty:

Little Falls Medical Group Survey

Section 1: MVHS Little Falls Medical Group

Section 2: Little Falls Relocation

OPTIONAL DEMOGRAPHIC DISCLOSURE

We're sorry, this survey is only for patients over the age of 18. Thank you for your time, your survey results will not be recorded.