COHI Women's Health Assessment

Circle of Health International, a US-based non-profit, is doing a women's health needs assessment in central Oklahoma. If you are a woman aged 15-49 who was affected in some way by the tornadoes, please take 10 minutes to fill out this survey. The survey is anonymous, and the results will be compiled and presented to the the organizations doing relief work in Oklahoma so that they can better serve the needs of women and families. All information on this form is considered CONFIDENTIAL. We will not ask you for your name or any identifying information. When you have finished the survey, please forward the link you received to your friends and family members. The more women we hear from, the more useful this assessment will be to the women of Oklahoma. You can learn more about Circle of Health International or submit questions at www.cohintl.org. Thank you!

1. Name of Interviewer (If no interviewer, put "Self"): *This question is required.

2. Date (must be in MM/DD/YYYY format!): *This question is required.

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3. Where did you live before the Oklahoma tornadoes? *This question is required.

4. Where do you live now? *This question is required.

5. How long have you been there? *This question is required.

6. How much longer will you be there? (If you don't know, put "Unknown") *This question is required.

7. Age: *This question is required. This question requires a valid number format.

8. Ethnicity:

9. Marital Status: *This question is required.

10. Children (if yes, how many, ages, and whether they are currently with/dependent on you): *This question is required.

11. Employment before and after tornadoes: *This question is required.

12. Estimated earnings for 2012:

13. What form of transportation did you use before the tornadoes? What form of transportation do you use now? *This question is required.

14. What are your primary women's health needs (please list them - examples would be reproductive health care, family planning, hormonal therapy, obgyn/midwifery care, supplements, etc)?

15. What has been your major obstacle to access women's health services:

17. If you answered "Other" to the previous question, please explain:

18. Where did you access these services?

19. In your immediate circle of contacts, have violent crimes against women increased (domestic violence, sexual assault)?

20. Are there any women's health services you need, but are not able to access? (please describe)

21. Are there financial or access barriers to the women's health services you seek? (please describe)

22. Is transportation a barrier to you accessing the women's health services you need?

23. Is there anything else you would like to tell us about the women's health services or goods you need or use?

COHI Women's Health Assessment

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