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Montgomery County CHA

The Montgomery County Health Council would appreciate the community's input.

1. What is your age?

2. What is your gender?

3. What is the highest level of schooling that you have completed?

4. What is your race/ ethnicity? You can choose more than one.

5. What is your zip code?

6. Which of the following categories best describes your income?

7. Please indicate if the following topics are "Not a Problem", " Minor Problem" or "Major Problem"

Space Cell	Not a Problem	Minor Problem	Major Problem
Youth Obesity	Youth Obesity: Not a Problem	Youth Obesity: Minor Problem	Youth Obesity: Major Problem
Physical Activity	Physical Activity: Not a Problem	Physical Activity: Minor Problem	Physical Activity: Major Problem
Youth Nicotine Use	Youth Nicotine Use: Not a Problem	Youth Nicotine Use: Minor Problem	Youth Nicotine Use: Major Problem
Drug Overdose	Drug Overdose: Not a Problem	Drug Overdose: Minor Problem	Drug Overdose: Major Problem
Infant Mortality	Infant Mortality: Not a Problem	Infant Mortality: Minor Problem	Infant Mortality: Major Problem
Teen Births	Teen Births: Not a Problem	Teen Births: Minor Problem	Teen Births: Major Problem
Community Water Fluoridation	Community Water Fluoridation: Not a Problem	Community Water Fluoridation: Minor Problem	Community Water Fluoridation: Major Problem
Frequent Mental Distress	Frequent Mental Distress: Not a Problem	Frequent Mental Distress: Minor Problem	Frequent Mental Distress: Major Problem
3rd Grade Reading Level	3rd Grade Reading Level: Not a Problem	3rd Grade Reading Level: Minor Problem	3rd Grade Reading Level: Major Problem
Preventable Hospitalizations	Preventable Hospitalizations: Not a Problem	Preventable Hospitalizations: Minor Problem	Preventable Hospitalizations: Major Problem
Per Capita Personal Income	Per Capita Personal Income: Not a Problem	Per Capita Personal Income: Minor Problem	Per Capita Personal Income: Major Problem
Access to Parks & Greenways	Access to Parks & Greenways: Not a Problem	Access to Parks & Greenways: Minor Problem	Access to Parks & Greenways: Major Problem
Adult Obesity	Adult Obesity: Not a Problem	Adult Obesity: Minor Problem	Adult Obesity: Major Problem
Adult Smoking	Adult Smoking: Not a Problem	Adult Smoking: Minor Problem	Adult Smoking: Major Problem
Neonatal Abstinence Syndrome	Neonatal Abstinence Syndrome: Not a Problem	Neonatal Abstinence Syndrome: Minor Problem	Neonatal Abstinence Syndrome: Major Problem
Suicide	Suicide: Not a Problem	Suicide: Minor Problem	Suicide: Major Problem
Educational Attainment	Educational Attainment: Not a Problem	Educational Attainment: Minor Problem	Educational Attainment: Major Problem
Diabetes	Diabetes: Not a Problem	Diabetes: Minor Problem	Diabetes: Major Problem
Immunizations	Immunizations: Not a Problem	Immunizations: Minor Problem	Immunizations: Major Problem
Adverse Childhood Experiences (ACEs)	Adverse Childhood Experiences (ACEs): Not a Problem	Adverse Childhood Experiences (ACEs): Minor Problem	Adverse Childhood Experiences (ACEs): Major Problem
Heart Disease	Heart Disease: Not a Problem	Heart Disease: Minor Problem	Heart Disease: Major Problem
Cancer	Cancer: Not a Problem	Cancer: Minor Problem	Cancer: Major Problem
Uninsured Rate	Uninsured Rate: Not a Problem	Uninsured Rate: Minor Problem	Uninsured Rate: Major Problem
Enter another option	Other: Not a Problem	Other: Minor Problem	Other: Major Problem
Enter another option	Other: Not a Problem	Other: Minor Problem	Other: Major Problem

8. Please select the top three issues in your community.

First Choice
Second Choice
Third Choice

9. From the following question, please indicate how satisfied you are with the efforts being made to address the topics in your community.

Space Cell	Very Dissatisfied	Dissatisfied	Neither Satisfied nor Dissatisfied	Satisfied	Very Satisfied
First Choice	First Choice: Very Dissatisfied	First Choice: Dissatisfied	First Choice: Neither Satisfied nor Dissatisfied	First Choice: Satisfied	First Choice: Very Satisfied
Second Choice	Second Choice: Very Dissatisfied	Second Choice: Dissatisfied	Second Choice: Neither Satisfied nor Dissatisfied	Second Choice: Satisfied	Second Choice: Very Satisfied
Third Choice	Third Choice: Very Dissatisfied	Third Choice: Dissatisfied	Third Choice: Neither Satisfied nor Dissatisfied	Third Choice: Satisfied	Third Choice: Very Satisfied