AFRICAN HOPE COMMITTEE INC.

Health Survey

The purpose of this community health survey is to collect information on your access to health education, immigration and social services within the African immigrant population and other minority immigrant population residing in New York City. The information is strictly confidential and anonymous.

I. DEMOGRAPHIC:

1. What is your country of birth?

2. Are you a male? or a female?

3. What is your zip code?

4. How long have you been living in New York?

5. What language do you speak fluently?

6. Age: Are you married? Yes or No

7. Do you have any children? Yes or No . If yes how many?

II. SERVICES:

8. Do you have health insurance? Yes or No . If yes what type?

9. What is your level of education?

10. What is your principal source of income?

11. What is your immigration status?

12. Have you used health services since you live in New York? Yes or No

13. Have you used social services since you live in New York? Yes or No

14. Do you have access to health/social services in your area? Yes or No

15. Have you seen any health provider for the past 6mths/one year?

Yes or No

16. Do you have difficulty accessing the health care system? Yes or No

17. How have you been addressing/handling your health /social issues?

18. Are you depressed over these issues? Yes , No , Don't know

19. Do you need help? Yes , No , Don't know

20. If yes what type of services do you need help with?

21. Would you like African Hope Committee to contact you for the service you need? Yes , No . If yes please Name and Phone#

“Thank you for taking the time to fill out this survey”