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Raleigh County Family Resource Network

Family Survey

Section I. Describe your Family

1. How Old Are You ?

18-24 25-34 35-44 45-64 65 and up

2. Are There children in your household ?

Yes No

If so, How Many ?

1 2 3 4 5 6 7 8

How Old Are They ?

0-1 1-2 2-3 3-4 4-5 5-6 6-7 7-8 8-9 9-10 10-11 11-12 12-13 13-14 14-15 15-16 16-17 17-18 18-19

3. What race/ethnic group(s) are you ?

African-American Caucasian Latino Asian/American American Indian Other

4. What is your zip code ?

5. How Long Have you lived in this community ?

Section II: What are your perceptions of area ? (Name of Community in which you live)

6. How do you like living in this community ?

7. How connected do you feel in this community ?

8. How safe do you feel in this community ?

9. What are the best things about this community ?

10. What things about this community would you most like to see change ?

11. What would you be willing to do to help change this community ?

Section III: What are your perceptions of the health and social service system in Raleigh County?

12. Which of the following services do you use ? If not, Indicate why not.

A. Outreach, identification, and referral            Yes                No                     Why Not  

B. Linkage to public assistance                          Yes                No                     Why Not  

C. Case management/service coordination         Yes              No                    Why Not  

D. Housing assistance                                           Yes               No                    Why Not  

E. Transportation                                                   Yes               No                    Why Not  

F. Adult Education                                                Yes                No                    Why Not  

G. Employment assistance                                   Yes                No                    Why Not  

H. Childcare and child development                    Yes                No                    Why Not  

I. Youth Development                                           Yes                No                    Why Not  

J. Foster Care                                                        Yes                No                    Why Not  

K. Health Care                                                       Yes                No                    Why Not  

L. Health promotion programs                              Yes                 No                   Why Not  

M. Mental health                                                   Yes                 No                  Why Not  

N. Family counseling and support services          Yes                  No                  Why Not  

O. Services for children and adults with special needs Yes          No                  Why Not  

P. Alcohol/drug abuse prevention and treatment Yes                  No                  Why Not  

Q. Literacy                                                             Yes                  No                  Why Not  

R. Alternative health care                                     Yes                  No                  Why Not  

S. Parenting education                                           Yes                  No                  Why Not  

T. Crisis intervention                                             Yes                  No                  Why Not     

U. Civil rights and legal services                           Yes                  No                 Why Not  

V. Recreation                                                          Yes                  No                Why Not  

W. Dental                                                                Yes                   No               Why Not  

X. Vision Care                                                         Yes                   No               Why Not  

Y. Senior services                                                    Yes                   No              Why Not  

Z. Adult day health care                                           Yes                  No              Why Not  

AA. Emergency care                                                Yes                  No              Why Not  

BB. Other                                                                                                                                        

13. How Do you pay for Services ?

Privately Insured Medicare Medicaid General Relief Uninsured/Pay Myself

14. Please respond to the following statements about the health and social services system in Raleigh County

a. Children and Families receive adequate services as needed

Always Usually Sometimes Rarely Never Don't Know

b. Programs reach all children and families who need them

Always Usually Sometimes Rarely Never Don't Know

c. Services are easily accessible to families

Always Usually Sometimes Rarely Never Don't Know

d. Services for children and families are well-coordinated

Always Usually Sometimes Rarely Never Don't Know

e. Referrals are shared between agencies

Always Usually Sometimes Rarely Never Don't Know

f. There is problem solving among agencies to fill gaps in services

Always Usually Sometimes Rarely Never Don't Know

g. Children and families are a very high priority with health/social service agencies

Always Usually Sometimes Rarely Never Don't Know

h. Agencies are in conflict with one another

Always Usually Sometimes Rarely Never Don't Know

i. Agencies have conflicting rules and eligibility requirements

Always Usually Sometimes Rarely Never Don't Know

j. Duplication of services is a problem

Always Usually Sometimes Rarely Never Don't Know

k. Children and families face barriers to obtaining services

Always Usually Sometimes Rarely Never Don't Know

15. Please rate the overall quality of services you use

Excellent Good Fair Poor

16. What actions would best improve our service system in Raleigh County?

Section IV: How is your family's health ?

17. What is your health status ?

Excellent Good Fair Poor

18. Do you consider yourself

Overweight Underweight Average Weight for your build

19. Do you Exercise ?

Not at all Sometimes Often Almost Everyday Everyday

20. Tobacco Use ?

Never Smoked Ex-Smoker Smoke Less then a pack daily Smoke 1+ packs daily Smoke 2+ packs daily Smoke pipe/cigar regularly Use smokeless tobacco

21. Do you have health insurance ?

Private Receive through work Medicaid Children's Health Insurance Program (CHIP) Medicare