Community Health Assessment Survey From Morgan County Missouri Health Center

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	104 W. Lafayette St. Versailles Missouri 65084 TEL: 573-378-5438 FAX: 573-378-2726

If you would like to participate in the online Community Health Assessment Survey you may do so here. Please do not complete the survey if you have done so within the past year. The survey is completely confidential, we do not ask for your name, email, or any personal identification whatsoever. We encourage you to read our privacy statement. Please answer the questions as truthfully as possible.

What is a community Assessment survey?

In 1988 the Institute of Medicine (IOM) of the National Institutes of Health published The Future of Public Health (Washington, D.C.: National Academy Press, 1988). This document defined public health and put public health activities into three broad functional categories which are now commonly called core functions. The three core functions are:

Assessment
Policy Development
Assurance

The assessment function should be conducted every three to 5 years. It gives the public health agency a good overall picture of the health status and health needs of the community. It includes data from surveys, statistics collected continually on communicable diseases reported in the community, census data that describes the population, and data from other sources. Taken together, all of this information paints a portrait of the community. Are a lot of people concerned with cancer? How many of us could stand to lose a few (or many) pounds? What percent of residents have health insurance and what kind and what percent are uninsured?

This community "portrait" helps the Morgan County Health Center develop, maintain and improve programs that are needed, and that you want, in areas that you think are important. By doing assessment periodically a health department can see if needs are shifting and react accordingly. This process helps in using resources more effectively.

Community Health Assessment Survey
Fields which are maroon in color are required.

[1] County In Which You Live:	[2] How long have you been a resident?	[3] Zipcode (5 digit only)
[4] Your Age:	[5] Your Sex:	[6] Racial/Ethnic identification:
[7] Education:	[8] Employment Status:	[9] Your Yearly Income:
[10] Do you have health insurance?	[11] If you have health insurance, what kind(s) - check all that apply. Private - traditional Managed Care (HMO, PPO, etc.) Medicare Medicaid (or MC+) Government (VA, CHAMPUS) Other Don't Know
[12] How do you rate your health?	[13] When was your last physical check up?	[14] Where do you go for routine health care?
[15] Can you see a doctor when you need to? Yes No	[16] If you can't see a doctor, then why not (choose only one please)?	[17] Do you regularly go outside your county for health services? Yes No
[18] If you regularly go outside your county for health services, what services? Medical - doctor appointments Outpatient treatment Hospitalization Dental appointments Laboratory or other tests X-Rays Other
[19] If you regularly go outside your county for health services, why?		[20] Where do you get most of your health-related information? Is it from: (please choose one)
[21] Select any of the following that you have had done in the last year: Mammogram Pap Smear Glaucome Test Flu Shot Colon/Rectal Examination Blood Pressure Check Blood Sugar Check Skin Cancer Screening Prostate Cancer Digital Screening Prostate Cancer PSA Screening Chloresterol Screen
[22] Who do you think is most responsible for keeping you healthy? (Please choose only one)

Thank you!

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104 W. Lafayette St. • Versailles, Missouri 65084 • 573-378-5438 or 5439

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