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Fulton County Medical Center and its community partner Fulton County Family Partnership is gathering information as part of a plan to improve health and quality of life in the community it serves.  Community input is essential to this process.  This survey is being used to engage community members.  

Some of the following survey questions are open-ended.  In these instances, we are trying to gather your thoughts and opinions.  There are no right or wrong answers.  The themes that emerge from these questions will be summarized and made available to the public; however, your identity will be kept strictly confidential.

It will take approximately fifteen minutes to complete the questionnaire.  Your participation in this study is completely voluntary.  There are no foreseeable risks associated with this project. However, if you feel uncomfortable answering any questions, you can withdraw from the survey at any point.  It is very important for us to learn your opinions. 

If you have questions at any time about the survey or the procedures, you may contact Aaron Hershberger at (513) 562-5560 or by email at ahershberger@bkd.com.

Thank you very much for your time and support.

How would you rate your (personal) overall health?
Overall, how would you rate the health status of your community?
In general, how satisfied are you with your quality of life?
What would improve the quality of life within your community? Please check all that apply.
Do you have one person you consider your personal care doctor or primary care provider?
Have you had a visit with your personal care doctor or primary care provider within the past year?
Have you had a dental visit within the past year?
Stress means a situation in which a person feels tense, restless, nervous, or anxious, or is unable to sleep at night because his/her mind is troubled. Within the last 30 days, how often have you felt any kind of stress?
Looking at the following items think about what causes stress in your daily life. Stress could be caused from not having the following, or being able to find them, or not having the preferred quality. Please check all that apply.
Was there a time in the past 12 months when you experienced any of the following?
Yes
No
Don't Know
Ate less food than you felt you should because there wasn’t enough money for food?
Used a food pantry/soup kitchen, or received a food donation?
Ran out of food and did not have enough money to purchase more?
Been unable to purchase healthy foods due to cost?
Had your utility company shut off your service for not paying your bills?
Needed to see a doctor, but could not because of cost?
Gone without health care because you did not have a way to get there?
Yes
No
Don't Know
Gone without medications due to cost?
Gone without health care because of the cost of your copay or deductible?
Been unable to pay your rent or mortgage?
Slept outside, in a shelter, or in a place not meant for sleeping?
Moved in with a family member or friend because you did not have anywhere else to stay?
Spent a few nights with family members or friends because you did not have anywhere else to stay?
Gone without needed childcare items (such as diapers, formula, car seat, crib, etc.)?
Yes
No
Don't Know
Been unable to make home repairs due to cost?
As a child (during the first 18 years of life) did you experience any of the following?
Yes
No
Don't Know
Did you or anyone in your family ever experience physical or emotional abuse?
Did you ever feel alone, isolated, or have no one to talk to?
Did you experience the separation, divorce, or breakup of a family?
Are you personally, or is anyone in your family currently experiencing any of the following? Please check all that apply.
How safe from crime do you consider the following?
Extremely Unsafe
Unsafe
Safe
Extremely Safe
Don’t Know
Your neighborhood
Your workplace
Your local school(s)
Your home
How much of a problem are the following related to housing in your community?
Not a Problem1Somewhat of a ProblemBig Problem
Landlords not maintaining properties resulting in poor living conditions
Run down or abandoned properties
Individuals moving in with a relative because of cost of housing
Several families living in one house
People “couch surfing”, spending a few nights at several people’s homes but do not have their own home
Please rate your level of confidence in the following emergency services:
Not at all ConfidentSomewhat ConfidenttExtremely Confident
An ambulance would respond quickly to my home if I needed it
The fire department would respond quickly to my home if I needed it
The police department would respond quickly to my home if I needed it
Please rate your level of agreement with the following statements:
Strongly agree
Agree
Neutral
Disagree
Strongly disagree
Underage drinking is a problem in our community
A minor would be caught by the police if they were drinking or using drugs
Parents in our community do not tolerate underage drinking
It is easy for minors in our community to get alcohol
It is easy for minors in our community to get drugs
Youth crime/delinquency is a problem in our community
Please rate your level of agreement with the following statements:
Strongly agree
Agree
Neutral
Disagree
Strongly disagree
I have taken someone else’s prescription pain medication
I have given someone else medication that was prescribed to me
Prescription drug abuse is a problem in our community
Prescription drug abuse is a problem in my family
Alcohol abuse is a problem in our community
Illegal drug abuse is a problem in our community
NARCAN should be available for use in homes
NARCAN (naloxone) is a prescription medication used for the treatment of an opioid emergency such as an overdose or possible overdose. Have you or do you know anyone who has done the following?:
Yes
No
Don't Know
I have had it given to me to stop an overdose
I know someone who has had it given to them to stop an overdose
I have personally given it to stop someone from overdosing
I know someone who has given it to stop someone from overdosing
Do you currently use e-cigarettes or vaping pens?
Do you currently use chewing tobacco, snuff, or snus? (Note: snus [Swedish for snuff] is a moist smokeless tobacco, usually sold in small pouches that are placed under the lip against the gum)
Do you currently smoke cigarettes?
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