The Crawford County Community Health Needs Assessment

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

The Meadville Medical Center & Titusville Area Hospital are conducting this survey to identify the health needs in our community. Every resident of Crawford County is invited to participate.

We need to hear from you. Please take 10-15 minutes to complete this survey.

This survey will NOT ask for your name, address or other identifiable information; however, you must reside in Crawford County (PA) in order to participate. You do not have to answer any question that you do not feel comfortable answering. All information recorded through this survey will remain confidential.

TELL US ABOUT YOURSELF.

In order to identify the health needs throughout Crawford County, we need to know a little bit more about you.

What city or town in Crawford County do you live in/near?

Please select all that apply to you.

I am deaf or hard of hearing

I am blind or have trouble seeing even when I am wearing my glasses

I have trouble concentrating, remembering, or making decisions because of a physical, mental, or emotional condition

I have trouble walking or climbing stairs

I have trouble getting dressed or taking a bath or shower

I have difficulties doing errands alone such as visiting a doctor's office or shopping

None of these apply to me

What is the highest grade or level of education you have finished?

How old are you?

What is your race? Select all that apply.

American Indian or Alaska Native

Asian

Black

Native Hawaiian or other Pacific Islander

White

Prefer not to answer or do not know

Other:

In 2021, what was your total annual household income before taxes?

What type of health insurance do you have?

I currently do not have health insurance

Medicaid

Medicare (for those 65+ or with disabilities)

Private health insurance

I do not know

Other:

Clear selection

What is your biological sex?

Male

Female

Prefer not to disclose

Clear selection

Which of the following best describes your current work situation?

Retired

A homemaker

Employed full time (35+ hours per week)

Employed part-time (less than 35 hours per week)

Unemployed

Full-time student

Other:

Clear selection

Please select the TWO sources that you go to for the most reliable and up-to-date information about health and medicine.

Social media (Twitter, Facebook, Instagram)

Government websites (cdc.gov or pa.gov)

News outlets (newspapers, TV, radio)

Friends and family

Government officials

Community organizations (local school, your employer, businesses)

Other:

Clear form

Never submit passwords through Google Forms.

This form was created inside of Allegheny College. Report Abuse

Forms