Attachment E
Community action network survey
The Healthy Start Community Action
Network (CAN) Survey
February 5, 2014
Public
Burden Statement:
An agency may not conduct or sponsor, and a person is not required
to respond to, a collection of information unless it displays a
currently valid OMB control number. The OMB control number for this
project is 0915–0338. Public reporting burden for this
collection of information is estimated to average 45 minutes per
response, including the time for reviewing instructions, searching
existing data sources, and and completing and reviewing the
collection of information. Send comments regarding this burden
estimate or any other aspect of this collection of information,
including suggestions for reducing this burden, to: HRSA Reports
Clearance Officer, 5600 Fishers Lane, Room 10-49, Rockville, MD
20857.
The instrument is designed in a self-administered web format, estimated at 30 to 45 minutes in length.
The survey will be deployed only in English.
Text fills, noted in this instrument with use of brackets and text in all caps [FILL] are assumed as follows:
[ORG NAME] = Name of organization or agency completing the survey filled from sample file
[HEALTHY START GRANTEE] = Name of Healthy Start grantee
[CAN MEMBER] = Names of up to 10 CAN members filled from sample file. These will be identified by the respondent as the 10 active members of the CAN with which the respondent’s organization partners the most. If fewer than 10 organizations are identified, that is the number of organizations that will be filled.
The question source is listed in parentheses at the end of each survey item. If an item is new, the word new is used to describe the source. This will not be displayed to respondents. Sources include the following:
2011 National Healthy Start Project Survey
Community Voices for Coverage Leadership Team Follow-Up Survey
Living Cities Grantee-Partner Network Survey
Social Capital Assessment Tool Household Survey
Social Capital Assessment Tool Community Questionnaire
Survey of the Health of Adults, the Population and the Environment 2002
Wilder Collaboration Factors Inventory
Items that allow multiple responses have the instruction to “select all that apply” and items allowing only a single response have the instruction to “select only one.”
The instrument will be completed by CAN board members and committee chairs representing an organization that is formally or informally partnered with Healthy Start. Individuals in the community who are part of the CAN but do not represent a partner organization will not be asked to complete the Healthy Start CAN survey as the purpose of the survey is to assess the organizational networks in the community. Healthy Start participant perspectives will be captured through focus groups.
The Healthy Start Community Action
Network (CAN) Survey
Thank you for taking the time to complete this survey! As part of the national evaluation of the Healthy Start program, we want to learn about your organization’s experience working with Healthy Start and serving as a board member or committee chair of the Community Action Network (CAN) under Healthy Start’s current funding cycle, which started approximately September 2014. The CAN is an existing, formally organized partnership, advisory board, or coalition of organizations and individuals representing consumers and appropriate agencies that unite in an effort to collectively apply their resources to the implementation of one or more common strategies to improve the lives of women, children, and their families within a community. The questions in this survey will ask about your organization, your experience collaborating with [HEALTHY START GRANTEE] and your experiences as a member of the CAN. This survey should take approximately 30 to 45 minutes to complete.
The evaluation is being funded by the Health Resources and Services Administration’s (HRSA) Maternal and Child Health Bureau (MCHB). The information we obtain will be used for research purposes only. All of the information you provide will be kept confidential. The evaluation will not identify individuals or organizations in its reports to the MCHB.
The table below shows the sections of the survey and the questions in each section.
|
SECTION |
QUESTIONS |
A |
ORGANIZATIONAL INFORMATION |
A1-A5 |
B |
COMMUNITY ACTION NETWORK PARTICIPATION |
B1-B5 |
C |
INFRASTRUCTURE FOR COLLABORATION |
C1-C4 |
D |
QUALITY OF COLLABORATION |
D1-D4 |
E |
PROGRESS TOWARD ACHIEVING GOALS |
E1-E4 |
F |
THE COMMUNITY |
F1-F3 |
G |
OTHER COMMENTS |
G1 |
Instructions
Answer the questions by clicking your mouse on the appropriate box.
After you have answered the questions on one page, click the next button at the bottom of the page to continue. To go back to a previous page, click the back button.
If you have to stop, you can log out of the survey by closing your browser. You can return to the survey later by clicking on the link in your email.
When you reenter the survey, your previous answers will be saved. You also will be able to change your previous answers, if necessary.
Please complete the survey by [DATE]. If you have any questions about the survey, please contact [NAME] via email [EMAIL] or by telephone at [TELEPHONE NUMBER].
The first set of questions collects general information about [ORG NAME].
Select all that apply.
HEALTH AGENCY/PROVIDER
State Title V agency 1
Medicaid agency 2
Local health department 3
Federally qualified health center 4
Private physician practice 5
Hospital 6
Mental health agency 7
Substance abuse treatment center 8
Other health agency/provider [SPECIFY] 9
Specify (STRING 200)
PUBLIC SOCIAL SERVICE AGENCY/PROVIDER
WIC agency 10
Welfare agency 11
Child protective service agency 12
Head Start/Early Head Start organization 13
Child care agency 14
Public School 15
Court 16
Substance abuse treatment center 17
Other public social service agency [SPECIFY] 18
Specify (STRING 200)
COMMUNITY-BASED AGENCY/PROVIDER
Faith-based organization 19
Advocacy organization 20
Professional
association (for example, Association of Maternal and Child
Health
Programs, American Congress of Obstetricians and Gynecologists) 21
Ethnic organization (for example, tribal organizations) 22
Civic group (for example, National Organization for Women) 23
Other community-based agency/provider [SPECIFY] 24
Specify (STRING 200)
Select all that apply.
Adult education services (GED, ESL) 1
Adult primary care 2
Child care (including resources, referrals, and services) 3
Domestic violence counseling/anger management counseling 4
Early
intervention services for children with
suspected/diagnosed
disabilities 5
Family planning and reproductive health services 6
Financial counseling services 7
Health insurance enrollment services 8
Housing/shelter services 9
Job training/employment services 10
Mental health services 11
Pediatric primary care 12
Substance (alcohol and other drug) use treatment 13
Teen support services 14
Transportation services 15
Youth education services 16
Women, infant, children (WIC) nutrition services 17
Other [SPECIFY] 18
Specify (STRING 200)
[ORG NAME] does not provide direct services 00
Your best estimate is fine.
Total: ______________________
Don’t know d
A3b. How many of the total served in the past year are women of reproductive age (15–44 years old)? (New)
Your best estimate is fine. If your organization does not serve women, enter 0.
Women (reproductive age): ______________________
Don’t know d
Your best estimate is fine. If your organization does not serve children under the age of 2, enter 0.
Children:____________________
Don’t know d
Your best estimate is fine.
|
Select one per row |
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|
Number of Staff Employed |
Don’t Know |
a. Total staff members |
______________________ |
d |
b. Full-time staff members (35 or more hours a week) |
______________________ |
d |
c. Part-time staff members (less than 35 hours a week) |
______________________ |
d |
Select all that apply.
Federal grants 1
State grants 2
County funds 3
Foundation funding 4
Private funding 5
Organizational revenue 6
Other 7
Specify (STRING 200)
This next section asks about [ORG NAME]’s involvement with [Healthy Start Grantee] and the Community Action Network (CAN).
The CAN is an existing, formally organized partnership, advisory board or coalition of organizations and individuals representing consumers and appropriate agencies who unite in an effort to collectively apply their resources to the implementation of one or more common strategies to improve the lives of women, children, and their families within a community.
____/____
(MM/YYYY)
Don’t know d
____/____
(MM/YYYY)
Don’t know d
____/____
(MM/YYYY)
Don’t know d
Select one only
Not at all 1
Little extent 2
Moderate extent 3
Great extent 4
Very great extent 5
Select one only
Not at all 1
Little extent 2
Moderate extent 3
Great extent 4
Very great extent 5
The next section asks about activities that [ORG NAME] may have been involved in with [Healthy Start Grantee], CAN members, and other organizations in the community during the past 12 months.
The CAN is an existing, formally organized partnership, advisory board or coalition of organizations and individuals representing consumers and appropriate agencies who unite in an effort to collectively apply their resources to the implementation of one or more common strategies to improve the lives of women, children, and their families within a community.
Select 10 organizations.
[FILL CAN MEMBER #1] 1
[FILL CAN MEMBER #2] 2
[FILL CAN MEMBER #3] 3
[FILL CAN MEMBER #4] 4
[FILL CAN MEMBER #5] 5
[FILL CAN MEMBER #6] 6
[FILL CAN MEMBER #7] 7
[FILL CAN MEMBER #8] 8
[FILL CAN MEMBER #9] 9
[FILL CAN MEMBER #10] 10
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SELECT ALL THAT APPLY |
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Community Action Network Members |
[ORG NAME] signed formal memorandum of understanding with organization |
[ORG NAME] met with organization for joint planning outside of CAN meetings |
[ORG NAME] participated in collaborative group or working group with organization in addition to the CAN |
[ORG NAME] submitted joint grant proposal |
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[LIST OF CAN MEMBERS FROM C1] |
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SELECT ALL THAT APPLY |
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Community Action Network Members |
[ORG NAME] made referrals to organization |
[ORG NAME] received referrals from organization |
[ORG NAME] shared/used the same data system |
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[LIST OF CAN MEMBERS FROM C1] |
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SELECT ALL THAT APPLY |
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Community Action Network Members |
[ORG NAME] organized/ implemented grassroots activities (for example, health fair or other community events) |
[ORG NAME] participated in joint training with organization |
[ORG NAME] developed joint program materials |
[ORG NAME] met with policymaker or attended public meeting or hearing with the organization |
[ORG NAME] developed media messages/ organized media events |
[ORG NAME] assessed or “mapped” community needs using data |
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[LIST OF CAN MEMBERS FROM C1] |
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The following questions are about [ORG NAME]’s experiences as a member of the CAN.
The CAN is an existing, formally organized partnership, advisory board or coalition of organizations and individuals representing consumers and appropriate agencies who unite in an effort to collectively apply their resources to the implementation of one or more common strategies to improve the lives of women, children, and their families within a community.
|
Select one per row |
||||
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Strongly disagree |
Disagree |
Neutral/ no opinion |
Agree |
Strongly agree |
Collaboration in the community |
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a. Agencies/organizations in our community have a history of working together. (Wilder Collaboration Factors Inventory, 1) |
1 |
2 |
3 |
4 |
5 |
b. Trying to solve problems through collaboration has been common in this community. It’s been done a lot before. (Wilder Collaboration Factors Inventory, 2) |
1 |
2 |
3 |
4 |
5 |
c. Others (in this community) who are not a part of the CAN would generally agree that the organizations involved in the CAN are the “right” organizations to make this work. (Wilder Collaboration Factors Inventory, 4 modified) |
1 |
2 |
3 |
4 |
5 |
d. The political and social climate seems to be “right” for starting a collaborative project like the CAN. (Wilder Collaboration Factors Inventory, 5 modified) |
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5 |
Resources |
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e. The CAN encourages effective and equitable allocation of limited resources. (New) |
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5 |
f. The CAN is able to adapt to changing conditions, such as fewer funds than expected, changing political climate, or change in leadership. (Wilder Collaboration Factors Inventory, 22 modified) |
1 |
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4 |
5 |
Representation |
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g. The people involved in the CAN represent a cross section of those who have a stake in what we are trying to accomplish. (Wilder Collaboration Factors Inventory, 9 modified) |
1 |
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4 |
5 |
h. All the organizations that we need to be members of the CAN have become members of the CAN. (Wilder Collaboration Factors Inventory, 10 modified) |
1 |
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4 |
5 |
i. The provider membership on the CAN is culturally representative of the target community. (New) |
1 |
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5 |
j. People in the CAN have a clear sense of their roles and responsibilities. (Wilder Collaboration Factors Inventory, 20 modified) |
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5 |
k. There is a clear process for making decisions among the members in the CAN. (Wilder Collaboration Factors Inventory, 21 modified) |
1 |
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5 |
Commitment |
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l. The organizations that belong to the CAN invest the right amount of time in our collaborative efforts. (Wilder Collaboration Factors Inventory, 13 modified) |
1 |
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5 |
m. The level of commitment among the CAN members is high. (Wilder Collaboration Factors Inventory, 15 modified) |
1 |
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5 |
n. The CAN has tried to take on the right amount of work at the right pace. (Wilder Collaboration Factors Inventory, 24 modified) |
1 |
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5 |
Communication |
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o. People in the CAN communicate openly with one another. (Wilder Collaboration Factors Inventory, 26 modified) |
1 |
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5 |
p. I am informed as often as I should be about what goes on in the CAN. (Wilder Collaboration Factors Inventory, 27 modified) |
1 |
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5 |
q. The leaders of the CAN disseminate information using a variety of modalities and technologies. (New) |
1 |
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4 |
5 |
r. The people who lead the CAN communicate well with the members. (Wilder Collaboration Factors Inventory, 28 modified) |
1 |
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5 |
s. Communication among the people in the CAN happens both at formal meetings and in informal ways. (Wilder Collaboration Factors Inventory, 29 modified) |
1 |
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5 |
Mutual respect, understanding, and trust |
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t. People involved in the CAN always trust one another. (Wilder Collaboration Factors Inventory, 7 modified) |
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5 |
u. I have a lot of respect for the other people involved in the CAN. (Wilder Collaboration Factors Inventory, 8 modified) |
1 |
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5 |
v. My organization benefits from being involved in the CAN (Wilder Collaboration Factors Inventory, 11 modified) |
1 |
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5 |
Goals |
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w. People in the CAN know and understand our goals. (Wilder Collaboration Factors Inventory, 32 modified) |
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5 |
x. People in the CAN have established reasonable goals. (Wilder Collaboration Factors Inventory, 3 modified) |
1 |
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5 |
y. What we are trying to accomplish as the CAN would be difficult for any single organization to accomplish by itself. (Wilder Collaboration Factors Inventory, 36 modified) |
1 |
2 |
3 |
4 |
5 |
Select one only
Not very productive 1
Moderately productive 2
Very productive 3
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Please check one response per row |
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Organization |
We do not work together at all |
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We work closely |
[LIST OF CAN MEMBERS FROM C1] |
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SELECT ONE ON EACH LINE |
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Community Action Network Members |
Not productive |
Somewhat productive |
Very productive |
Can’t assess |
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[LIST OF CAN MEMBERS FROM C1] |
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The next questions ask about the CAN’s goals.
If there are more than three goals, please list the top three.
COLUMN A |
COLUMN B |
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Main Goals |
Not effective |
Somewhat effective |
Very effective |
Do not know |
______________________________ |
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______________________________ |
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______________________________ |
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Select up to five.
Competing agendas of member organizations 1
Insufficient resources in the state or community to support our CAN goals 2
Insufficient staff time dedicated to assisting the CAN in its efforts 3
Irregular CAN attendance by key members 4
Lack
of collaboration/cooperation from necessary partners
and
stakeholders 5
Lack
of history of collaborative effort among health and
service
providers in our community 6
Lack of participant involvement 7
Lack of resources for CAN activities 8
Lack of strategic plan for the CAN 9
Lack of strong CAN leadership 10
Unstable relationships among CAN members 11
Unsupportive political climate 12
Other (specify) 99
Specify (STRING 500)
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Select one for each row below . . . |
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Outcomes |
Does not focus on this |
Focuses on this to some extent |
Focuses on this to a great extent |
Do not know |
a. Processes to support access to comprehensive care |
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b. Navigation across health and social service systems |
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c. Coordination and integration of care across health and social service systems |
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d. Community mobilization and involvement |
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e. Capacity to address social determinants of health |
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f. Stability of families in the community |
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g. Data systems to coordinate and provide care across organizations |
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h. Integration of consumers into the planning of services |
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Select one for each row below . . . |
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Outcomes |
Made no impact |
Made some impact |
Made major impact |
Do not know |
a. Processes to support access to comprehensive care |
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b. Navigation across health and social service systems |
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c. Coordination and integration of care across health and social service systems |
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d. Community mobilization and involvement |
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e. Capacity to address social determinants of health |
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f. Stability of families in the community |
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g. Data systems to coordinate and provide care across organizations |
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h. Integration of consumers into the planning of services |
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The next questions ask about the community that [ORG NAME] is located in.
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Select one for each row below . . . |
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Strongly agree |
Agree |
Disagree |
Strongly disagree |
Trust |
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a. People can depend on each other in this community. (Survey of the Health of Adults, the Population and the Environment 2002, 13a) |
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b. People know they can get help from the community if they are in trouble. (Survey of the Health of Adults, the Population and the Environment 2002, 13c) |
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c. Generally speaking, most people in the community can be trusted. (Social Capital Assessment Tool Household Survey, 5B10 modified) |
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d. Differences between people living in the community (such as differences in education, wealth, race, religious beliefs, or ethnic background) tend to divide the community. (Social Capital Assessment Tool Household Survey, 4C1 modified) |
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Community Participation and Mobilization |
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e. People in the community are inclined to attend local events like school concerts, religious gatherings, or neighborhood fairs. (Survey of the Health of Adults, the Population and the Environment 2002, 12 modified) |
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f. Individuals often join together with other people in the community to address a common issue. (Social Capital Assessment Tool Household Survey, 4D3 modified) |
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g. Most people feel accepted as a member of the community. (Social Capital Assessment Tool Household Survey, 5B10i modified) |
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Access |
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h. People in the community often have difficulty accessing services like health care or social services. (New) |
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i. It is common for people in the community to be excluded from access to services due to income level, gender, race, ethnicity, religious beliefs, or education level. (New) |
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j. People in the community have access to phone and Internet, either through personal devices or public sources (like libraries). (New) |
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Well-Being in the Community |
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k. This community is a good place to raise children. (Survey of the Health of Adults, the Population and the Environment 2002, 13d) |
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l. People here look out mainly for the welfare of their own families, and they are not much concerned with community welfare. (Social Capital Assessment Tool Community Questionnaire, 1.19) |
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m. Residents generally feel secure living in this community. (Survey of the Health of Adults, the Population and the Environment 2002, 13b modified) |
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Select one only
Improved 1
Worsened 2
Remained the same 3
Select one only
No impact 1
Small impact 2
Moderate impact 3
Big impact 4
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File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
Author | Katie M |
File Modified | 0000-00-00 |
File Created | 2021-01-27 |