Community Chronic Disease Survey 2026
Jackson County Public Health is conducting this survey as part of our Chronic Disease Grant through the Missouri Department of Social Services. Your feedback will help us better understand the health needs of our community and improve future programs and services. You must be over the age of 18 to complete this form. Responses are anonymous and will only be reported as part of a group. At the end of the survey, you can choose to sign up for a focus group to share more about your experiences. Contact information for the focus group will be kept separate from your survey responses. If you have questions about this survey, please contact Grace Crawford grace.crawford@uhkc.org or (816) 404-6532. The first 100 participants who complete the survey will receive a $10 gift card for their time and participation, only 1 gift card per household. Thank you for helping us build a healthier community!
I comfirm that I am 18 years of age or older?
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Yes, I'm 18 years old or older
No, I am under the age of 18
Demographics
What is your ZIP Code?
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What is your age?
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18-24
25-34
35-44
45-54
55-64
Prefer not to answer
What is your race or ethnicity? (select all that apply)
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American Indian or Alaska Native
Asian
Black or African American
Hispanic or Latino/a
White
Prefer not to answer
Gender Identity
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Female
Male
Non-Binary
Prefer not to answer
Prefer to self-describe
Annual Household Income
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Less than $15,000
$15,000-$24,999
$25,000-$34,999
$35,000-$49,999
$50,000-$74,999
$75,000-$99,999
$100,000 or more
Personal Health Status
How would you describe your general health?
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Excellent
Very Good
Good
Fair
Poor
How has your health changed in the last 5 years?
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Better
Worse
Same
What Chronic Diseases have the biggest impact on your daily life?
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Cancer
Heart disease
Diabetes
Asthma or other respiratory diseases
Obesity
Tobacco related illness
substance use disorder
Other
In a typical month, how often do you help care for someone with Chronic Disease by helping with their daily activities?
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Daily
Several times a week
About once a week
2-3 times a month
Once a month
Never
Have you ever experienced limitations in your ability to work at a job, do housework, or go to school because of a chronic disease that you or someone in your household has?
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Yes
No
Some people make their health a top priority most of the time. Others try to make their health a priority, but work, family, or other responsibilities often come first. Which statement best describes you?
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Those who say they make their health a priority almost always
Those who say they often have to put other things ahead of their health
Other
In general, how confident are you about the following?
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Rows
Not confident at all
Not too confident
Somewhat confident
Very confident
Don't Know
When you need to get medical care for a health problem and when you can handle it on your own
Where to get medical care when you need it
You can get the care you need, when you need it
How to manage any health problems you may have
How to prevent health problems in the first place
Perceptions of Community Health
Overall, would you say that you live in a healthy community, an unhealthy one, or one that is somewhere in between?
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Healthy
Unhealthy
In between
Here is a list of some things that may affect people’s health. Please rate each on a scale from 1 to 5 where 1 means it has no effect on health and 5 means it has a very strong effect. The effect could be positive or negative. What we’re asking is how strong you think the effect is on people’s health.
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Rows
1 (no effect on health)
2
3
4
5 (very strong effect on health)
Don't Know
Access to healthcare
Having a job
Stress
Quality of food available in the community
Having health insurance
Smoking
Personal health practices (other than smoking)
Air and water quality
Genetic makeup inherited from parents
Community safety
Housing quality
Education
Community a person lives in
How concerned are you about chronic diseases in your community?
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Very concerned
Somewhat concerned
Not very concerned
Not at all concerned
From your perspective, which chronic diseases have the greatest impact on your community? (Select up to 3.)
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Cancer
Heart disease
Diabetes
Asthma or other respiratory diseases
Obesity
Tobacco related illness
Substance use disorders
Other
Which of these statements do you agree with most?
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If people in your community worked together it would be easy to make it a healthier place to live.
If people in your community worked together it would not be easy, but it would be possible to make it a healthier place to live.
Even if people in your community worked together, it would be impossible to make it a healthier place to live.
Survey Completion Gift Card and Focus Group Information
If you would like to recieve a $10 gift card for your time completing the survey please fill out Name and Address boxes. If you would like to be contacted to participate in a focus group about Chronic Diseases, please fill out Name, Email and Phone Number boxes.
Name
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Submit Feedback
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