Appendix C – Community Member Survey Hoag Hospital Community Survey Thank you for your participation today. We are asking community members to complete this survey to provide your valuable feedback on Hoag Hospital’s Community Health Needs Assessment. We will be asking questions about 4 topics: COVID-19, physical health, mental health, and your demographic information. Your responses will be anonymous.
Part 1. COVID-19 In this first section, we’d like to better understand how COVID-19 is impacting individuals and communities. As such, the following questions are specific to COVID-19/Coronavirus/Novel Coronavirus. 1. How concerned do you feel about the COVID-19 pandemic? ❑ Not at all concerned ❑ A little concerned ❑ Very concerned ❑ Extremely concerned 2. Do you feel that you are at greater risk of becoming severely ill from COVID-19? Yes No a. Please indicate from the list below why you feel that you are at greater risk of becoming severely ill from COVID-19. (select all that apply) ❑ I identify as a racial/ethnic minority ❑ I am immunocompromised (i.e. have a weakened immune system) ❑ I have a chronic health condition ❑ I live in crowded housing ❑ I am an essential worker ❑ I am an older adult ❑ Other (please specify):________________ 3. Is social distancing or self-isolation having a negative impact on your mental health? ❑ Yes, Major Impact ❑ Yes, Minor impact ❑ No impact 4. Please indicate if you have experienced increases in any of the following symptoms related to concern or worry about COVID-19? ❑ Anxiety ❑ Depression ❑ Difficulty sleeping ❑ Fatigue
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