We value your opinion. Please take a few moments to give us your feedback today. Your comments will help us continue to meet the needs of our community.

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* 1. In general, what do you think the issues are that have the most impact on the overall quality of life in our community. Please pick three (3) from this list of community issues.

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* 2. What do you think are the three (3) biggest health problems impacting our community’s overall health. Please pick only three (3) from the list below.

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* 3. Please pick the top 3 unhealthy behaviors that you believe are a problem in our community.

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* 4. Our Community

  Strongly Agree Agree Disagree Strongly Disagree
There is a high quality healthcare system in our community.
Our community is a good place to raise children.
Our community is a good place to grow old.
There is plenty of economic opportunity in our community.
Our community is a safe place to live.
There is plenty of help for individuals and families in need in our community.
Please Tell Us About Yourself

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* 5. Ethnicity

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* 6. Age

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* 7. Do you speak a language other than English at home.

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* 8. In general, how would you describe your health?

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* 9. What is your home zip code?

Thank you for your time!

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