Return Date: March 31, 2005

Perry County Survey

Sponsored by: Perry County Community Task Force (Call 547-1292 for further information.)

1. Are you? ………………………………………………. Male ___ Female ___ Your age: _____

2. Which best describes your household?

Single ___ Married ___ Divorced ___ Widow(er) ___ Unmarried Couple ___

3. Highest level of education completed? …………………….. Self: _____ Spouse: _____

4. Do you own or rent your home? ………………………… Own ___ Rent ___ Other _____

5. Number of years you have lived in this community? Less than 1 ___ 1-4 ___ 5-9 ___ 10+ ___

6. Are you or anyone in your household disabled? ……………………………….. Yes ___ No ___

7. What is the current employment status of those in your household? …………

Self (you): Employed ___ Unemployed ___ Retired ___ Seeking Work ___

Your Spouse: Employed ___ Unemployed ___ Retired ___ Seeking Work ___

8. Do you or a member of your household commute to work outside Perry County? … Yes ___ No ___

9. What is your household income level? ………………… Less than $4,999 ___ $5,000-$9,999 ___

$10,000-$14,999 ___ $15,000-$24,999 ___

$25,000-$34,999 ___ $35,000-$49,999 ___

$50,000-$74,999 ___ $75,000-$99,999 ___

$100,000-$149,999 ___ $150,000 & Over ___

10. Total number of people in household? __________ Number of children in household? ________

11. Check the two best ways you believe the community can be educated on health related issues:

___ Newspaper ___Health Care Providers ___ Public Seminars/Screenings

___ Radio ___ Programs in Schools ___ Television

___ Direct Mail ___ Programs in Civic Organizations ___Posters/Signs in Community

Other: _____________________________________________________________________________

12. Do you feel the Perryville Police Dept. is doing an adequate job of crime prevention? Yes ___ No ___

13. How can Perryville Police services in the city be improved? ___________________________________

14. Would you support a sales tax to increase the salaries of the Sheriff’s deputies? Yes ___ No ___

15. Would you encourage commissioners to increase funding to allow for more deputies? Yes ___ No ___

16. Would you support a fire protection tax for Rural Perry County to pay for personnel

and better equipment? ………………………………………………………………. Yes ___ No ___

17. Do you feel those who host underage drinking parties should face consequences? … Yes ___ No ___

18. What agencies/groups do you feel are most effective for dealing with substance abuse?

___ Church ___ Law Enforcement ___ Mental Health/Counseling

___ Family ___ School ___ Prevention/Treatment Programs

___ Support Groups ___ Other _________________________

19. Do you have health insurance under (check all that apply):

___ Private ___ Medicare (Social Security) ___ Health Maintenance (HMO)

___ Provided by Employer ___ Medicaid (Public Aid) ___ No Insurance

20. Are you aware of the Domestic Violence Services in the County? ………………….Yes ___ No ___

21. Reasons Perry County citizens do not use available health care services (check all that apply):

___ Lack of transportation ___ Lack of trust in services ___ Lack of awareness

___ Inconvenient hours ___ Takes too long to be seen ___ Inability to pay

___ Insurance Limits Providers Other (please specify): _____________________________

22. If you decided to seek mental health treatment, would you know where to go? ………Yes ___ No ___

23. What mental health providers have you utilized (check all that apply)?

___ Community Counseling Center ___ PCMH Counseling Center ___ Private Practice

___ Substance Abuse Program ___ Other __________________________________________

24. What mental health services are you interested in seeing provided in Perry County? ________________

25. In what city/county is your family physician (doctor) located? _________________________________

26. Where have you sought healthcare in the past two (2) years?

___ Perry County Memorial Hospital ___ Cape Girardeau ___ St. Louis Other ______________

27. What services are you most interested in seeing at Perry County Memorial Hospital? _______________

28. If you have used Perry County hospital, were you treated with respect and dignity by PCMH staff?

……………………………………………………………………………………… Yes ___ No ___

29. Would you refer friends/family to Perry County Memorial Hospital? …………… Yes ___ No ___

30. What influenced you most in deciding where to seek your health care? ___________________________

____________________________________________________________________________________

31. Are you physically active at least 30 minutes? ___ Daily ___ Less than 3 times per week

___ 3 times per week or more ___ Never

32. Do you wear a seatbelt? ___Always ___ Most of the time ___ Sometimes ___ Never

33. Do you smoke? ___ Don’t smoke ___ Less than 1 pack a day ___ 1-2 packs per day ___ More

34. Do you drink alcohol (except for religious reasons)? ___ Never/Special Occasions

                    ___ Once a month or less

___ 1 day a week

____ 2 or more days a week

35. Do you feel it’s "okay" for youth under age 21 to drink at home or on

private property as long as they don’t drink and drive? ………………………… Yes ___ No ___

36. Have you or anyone in your household ever used any of the following drugs (check all that apply):

___ Marijuana ___ Methamphetamines ___ Cocaine ___ Heroine

___ Prescription drugs (misused) ___ Inhalants/Aerosols Other: _____________________

37. Our local public school system is (please circle one): ………………………….. Good Fair Poor

38. Our local parochial school systems are (please circle one): …………………….. Good Fair Poor

39. Do you feel Perry County schools are preparing students for college or work? … Yes ___ No ___

40. Would you like to see students disciplined in ways other than suspension?…….. Yes ___ No ___

41. Are you aware of the course offerings at the Perryville Area Higher Education Center? Yes ___ No ___

42. Are you attending? ___ Southeast MO State University ___ Mineral Area College ___ None

43. If so, what degree or major are you pursuing? ________________________________________

44. What programs or courses would you like offered at the Perryville Higher Education Center? …………

____________________________________________________________________________________

1 = no opinion 2 = not important 3 = somewhat important 4 = important 5 = very important

Alcohol Use/Abuse 1 2 3 4 5 Eating Disorders (Anorexia, Bulimia) 1 2 3 4 5

Other Drugs Use/Abuse 1 2 3 4 5 Suicide 1 2 3 4 5

Tobacco Use 1 2 3 4 5 Domestic Violence 1 2 3 4 5

School Dropout Rate 1 2 3 4 5 Child Abuse 1 2 3 4 5

Illiteracy (can’t read or write) 1 2 3 4 5 Learning Disorders 1 2 3 4 5

Unhealthy Sexual Behavior 1 2 3 4 5 Teenage Pregnancy 1 2 3 4 5

Unsupervised Children 1 2 3 4 5 Business’ Providing Teen Activities 1 2 3 4 5

Declining Moral Values 1 2 3 4 5 Knowledge of Available Services 1 2 3 4 5

Burglary/Robbery/Stealing 1 2 3 4 5 Assault 1 2 3 4 5

Vandalism 1 2 3 4 5 Murder 1 2 3 4 5

Crime (Juvenile) 1 2 3 4 5 Homelessness 1 2 3 4 5

Halfway House for Juveniles 1 2 3 4 5 Sexual Assault 1 2 3 4 5

Drinking Water Quality 1 2 3 4 5 Air Quality 1 2 3 4 5

Home/Property Maintenance 1 2 3 4 5 Public Transportation 1 2 3 4 5

Affordable Housing 1 2 3 4 5 Utility Rates 1 2 3 4 5

Tax Rates 1 2 3 4 5 Perry County Road Conditions 1 2 3 4 5

Additional Comments: _______________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

1 = no opinion 2 = not important 3 = somewhat important 4 = important 5 = very important

Importance Access to Service Your Satisfaction

1. Affordable Health Screenings 1 2 3 4 5 Good Fair Poor N/A Good Fair Poor N/A

2. Affordable Medication & Supplies 1 2 3 4 5 Good Fair Poor N/A Good Fair Poor N/A

3. Affordable Dental Services 1 2 3 4 5 Good Fair Poor N/A Good Fair Poor N/A

4. Family Planning Services 1 2 3 4 5 Good Fair Poor N/A Good Fair Poor N/A

5. Newborn Health Services 1 2 3 4 5 Good Fair Poor N/A Good Fair Poor N/A

6. Mental Health Crisis Prevention 1 2 3 4 5 Good Fair Poor N/A Good Fair Poor N/A

7. Mental Health Counseling 1 2 3 4 5 Good Fair Poor N/A Good Fair Poor N/A

8. Quality Child Care 1 2 3 4 5 Good Fair Poor N/A Good Fair Poor N/A

9. Child Support Payment Enforcement 1 2 3 4 5 Good Fair Poor N/A Good Fair Poor N/A

10. Meals on Wheels (Perryville) 1 2 3 4 5 Good Fair Poor N/A Good Fair Poor N/A

11. Meals on Wheels (Perry County) 1 2 3 4 5 Good Fair Poor N/A Good Fair Poor N/A

12. Home Assistance (Seniors) 1 2 3 4 5 Good Fair Poor N/A Good Fair Poor N/A

13. Affordable Housing 1 2 3 4 5 Good Fair Poor N/A Good Fair Poor N/A

14. Services for the Disabled 1 2 3 4 5 Good Fair Poor N/A Good Fair Poor N/A

15. Utilities & Housing Assistance 1 2 3 4 5 Good Fair Poor N/A Good Fair Poor N/A

16. Access to Food Pantries 1 2 3 4 5 Good Fair Poor N/A Good Fair Poor N/A

17. Recreational Opportunities 1 2 3 4 5 Good Fair Poor N/A Good Fair Poor N/A

18. Trash/Waste Disposal Services 1 2 3 4 5 Good Fair Poor N/A Good Fair Poor N/A

19. Continuing Education Services 1 2 3 4 5 Good Fair Poor N/A Good Fair Poor N/A

21. Parenting Skills Education 1 2 3 4 5 Good Fair Poor N/A Good Fair Poor N/A

22. Places of Worship & Training 1 2 3 4 5 Good Fair Poor N/A Good Fair Poor N/A
Thank you for caring enough about Perry County to complete this survey.
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