COMMUNITY HEALTH ASSETS

AND NEEDS ASSESSMENT

Berwyn, Cicero, Garfield Ridge, and North Stickney

ASSESSING HEALTH, ILLNESSES AND MEDICAL EXPERIENCES:

RESIDENTIAL SURVEY QUESTIONNAIRE ENGLISH

Alivio Medical Center

Berwyn Township Public Health District
Chicago Department of Public Health
Town of Cicero Health Department
Cook County Department of Public Health
Faith Community Reformed Church
Garfield Ridge Civic League
Interfaith Leadership Project
MacNeal Hospital
Pillars
Saint Jane de Chantal Parish
Solutions for Care
Stickney Public Health District
Robert Wood Johnson Foundation Center for Health Policy
University of New Mexico

A community-academic partnership implemented the Community Health Assets and

Needs Assessment (CHANA) 20112014 Study to fill information gaps, identify priorities,
and inform the development of interventions. The study focused in four areas Berwyn
Township, Town of Cicero, Garfield Ridge community, and three North Stickney Areas.
The Arthur Foundation, Community Memorial Foundation, Berwyn Township Board of
Health, and private donors funded the study. The Robert Wood Johnson Foundation
Center for Health Policy at the University of New Mexico sponsored the project. Two
Institutional Review Boards sanctioned the implementation of the health assessment.
Members of the Community Advisory Council oversaw the implementation of the CHANA
20112014 Study. Dr. P. Rafael Hernndez-Arias designed the research approaches and
directed the study. Community organizations, local residents, project coordinators, and
university students contributed to implement the four components of the project.
The study involved building profiles, interviewing key informants, assessing conditions and
resources, and surveying local physicians and area residents. The Residential Survey
assessed individual health, illnesses, and medical experiences, such as diagnosed illnesses,
medical services utilization, medical insurance, as well as health knowledge and practices.

Suggested citation: Hernndez-Arias, P. Rafael. 2012. Assessing Health, Illnesses, and

Medical Experiences: Residential Survey Questionnaire. Albuquerque, NM. Robert
Wood Johnson Foundation Center for Health Policy at the University of New Mexico.

The authors grant permission for the reproduction of this research instrument without
explicit permission as long as the source is included in the reproduction. User of sections
of the research instrument must indicate the source of the materials. For information
about the CHANA 20112014 Study visit, www.chana-project.org/chana2014/.

COMMUNITY HEALTH ASSETS AND NEEDS ASSESSMENT

Berwyn, Cicero, Garfield Ridge, and North Stickney
ASSESSING HEALTH, ILLNESSES AND MEDICAL EXPERIENCES:
RESIDENTIAL SURVEY QUESTIONNAIRE ENGLISH
Community Advisory Council Members:
Sheri Cohen, MPH Senior Analysts, Chicago Department of Public Health
Dianna Durica, Cook County Department of Public Health
Nereida Esparza, MD, Family Medicine Residency Program, MacNeal Hospital
Susana Gonzlez RN, Director, Womens Health, MacNeal Hospital
Susan Grazzini, RN, Director, Town of Cicero Health Department
Christopher Grunow PsyD, Director, Stickney Public Health District
Amy Harrison, MD, Family Medicine Residency Program, MacNeal Hospital
Hermilia Herrera BA, Pregnancy Testing Center, MacNeal Hospital
P. Rafael Hernndez-Arias, PhD, University of New Mexico
Jonathan Lopez, Community Health Assets and Needs Assessment
Tina Kloess RN, Nurse Services, Berwyn Township Public Health District
Anna Padron-Sikora, MA, Associate Vice President, Pillars
Elizabeth Pechous, Board President, Berwyn Township Public Health District
Ana Parra, MA, Executive Director, Interfaith Leadership Project
Kristin Pellegrino, MD, Family Medicine Residency Program, MacNeal Hospital
Sarah Saenz, Assistant Executive Director, Solutions for Care
Richard Techman, President, Garfield Ridge Civic League
Carmen Velsquez, MA, Founder, Alivio Medical Center
Fabiola Zavala MPH, Director of Volunteer Services, MacNeal Hospital
Prepared by:
P. Rafael Hernndez-Arias, PhD
Robert Wood Johnson Foundation Center for Health Policy
University of New Mexico
Funded by:
Arthur Foundation of Illinois
Community Memorial Foundation
Berwyn Township Board of Health
Private Donors

RESIDENTIAL SURVEY
The residential survey was one of the approaches employed to gathering information in the Community
Health Assets and Needs Assessment (CHANA) 20112014 Study. The community-academic partners
assessed health conditions, resources, and needs in Berwyn Township, Town of Cicero, Garfield Ridge
community, and North Stickney Areas. The North Stickney Areas included three communities in Stickney
Township, Village of Forest View, Village of Stickney, and the unincorporated area of Central Stickney.

Overall Research Design and Methodologies

The CHANA 20112014 Study involved participatory, community-based, and inductive approaches and
employed multiple qualitative and quantitative means of gathering information. Representatives from
nonprofits, medical and social service providers, faith-based, government, and academic institutions
implemented the study. The collective efforts and evolutionary approach contributed to keep the health
assessment rooted in the selected community areas as well as in academic research practices.
The health assessment involved eleven approaches to gather information about the communities, which
the research partners implemented in four stages. The first stage involved building community profiles
using available population and health information. The second stage captured perceptions from peerselected key informants about the social and health conditions. The third stage collected observations
about the social and physical conditions as well as food and medical resources. The last stage gathered
health, illness, and medical experiences from small groups of randomly selected area residents.

Residential Survey Design and Methods

The residential survey captured individual experiences with diagnosed illnesses and conditions, use of
medicine and medications, medical insurance coverage, as well as health knowledge and practices. The
survey involved a multi-stage cluster sampling approach to select a representative group of residents in
the selected areas. The sampling approach and the use of face-to-face interviews techniques facilitated
reaching out to populations often neglected in health surveys, such as individuals without telephones.
Implementing the health survey in phases aided to publicize the study and increased participation. The
project coordinator and community surveyors advertise the study in commercial spaces and at public
meetings. The selected residents received a letter informing them of the opportunity to represent the
community, describing the survey and the interview, and providing a telephone number and a website to
attain additional information. Trained surveyors visited the selected homes and conducted the interviews.
While the research design and approaches proved effective, the limited financial resources available
permitted the implementation of the residential survey only in Berwyn Township. The residential survey
provided unique perspectives from individual residents in the communities about how they experienced
health, illness, and medicine that helped the research partners to achieve the specific goals of the health
assessment. The CHANA 2011-2014 Study contributed to fill health information gaps, to identify health
priorities, and to inform the development of appropriate health interventions in the four areas.

RS Interview Questionnaire ENG 13-12-10

www.chana-project.org/chana2014/

Page 4 of 13

COMMUNITY HEALTH ASSETS

AND NEEDS ASSESSMENT
Berwyn, Cicero, Garfield Ridge, and North Stickney
Alivio Medical Center, Berwyn Township Public Health District, Chicago Department of Public Health, Town of Cicero
Health Department, Cook County Department of Public Health, Faith Community Reformed Church, Garfield Ridge
Civic League, Interfaith Leadership Project, MacNeal Hospital, Pillars, Saint Jane de Chantal Parish, Solutions for Care,
Stickney Public Health District, and RWJF Center for Health Policy at the University of New Mexico

RS Interview Questionnaire ENG 13-12-10

100
116
117

Tracking number

100|__|__|__|__|

Month and day of interview

116|__|__|__|__|

/
:

Starting time of the interview

117|__|__|__|__|

3.0 Residential Unit and Neighborhood

In the first set of questions, I would like to ask you about your residential unit.
300 How

many rooms are in this unit?

300|__|__|

How many of rooms are used for sleeping?

301|__|__|

How many bathrooms with showers are in the unit?

302|__|__|

How many smoke detectors are in the unit?

303|__|__|

304

How many carbon monoxide detectors are in the unit?

304|__|__|

305

How many areas have you seen with paint peeling off?

305|__|__|

How many kinds of pests have you seen in the unit?

306|__|__|

301
302

303

306

Do you own this residential unit?

No 1 Yes 2

307|__|__|

Were you born in this community?

No 1 Yes 2

308|__|__|

307
308

If yes, skip the next question, and show Card A.

309 What year did you come to live in this community?

309|__|__|__|__|

Show Card A: I like to ask about the frequency with which you feel about the topics I will read
to you. The options are, never (N), infrequently (I), sometimes (S), frequently (F), or always (A).
Please tell me, how often you feel...
1
2
3
4
5
310 Comfortable walking around here during the day
N
I
S
F
A

310|__|__|

That children in this area are safe

311|__|__|

Comfortable walking around here at night

312|__|__|

That the police presence here is as much as needed

313|__|__|

using the parks in this area

314|__|__|

That gangs are visibly present in this area

315|__|__|

Comfortable about the neighbors you have

316|__|__|

That there are racial tensions among people

317|__|__|

That your home is safe

318|__|__|

That the elderly in this area are safe

319|__|__|

Comfortable living in this area

320|__|__|

311
312
313

314 Comfortable
315
316
317

318
319

320

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4.0 Seeking Medical Services

Show Card A: next, I would like to ask about possible things you may do when you are sick. By
sick, I mean when you do not feel well enough to participate in daily activities.
When you get sick, how frequently do you
400 Do nothing until it becomes intolerable N
I
S
F
A
Ask for opinions about what you may have

Take home-made remedies, like a special soup

Take traditional medicines, such as an herbal infusion

Take medicines that do not require a prescription

Go to a traditional healer or practitioner

Go to a clinic at a store or a pharmacy

Go to see a private medical doctor

Go to a community clinic

Go to a hospital

401
402
403

404

405

406

407

408

409

410 Go to an emergency room N

I
S
F
A
Now, I would like to ask about ways you might pay for medical services, such as visits to
traditional healers, doctors, or medical exams.
How often do you pay for medical services with
411 Cash, check, or debit card N
I
S
F
A

__|
401|__ |__|
402|__ |__|
403|__ |__|
404|__ |__|
405|__ |__|
406|__ |__|
407|__ |__|
408 |__ |__|
409|__ |__|
410|__ |__|

A credit card

Public insurance, such as Medicaid

Private insurance, such as Blue Cross

Other form of payment

|__|
412|__ |__|
413|__ |__|
414|__ |__|
415|__ |__|

An installment payment plan

416|__

sliding scale payment program

Services provided free of charge

412
413
414

400|__|

415

411|__

In paying for medical services, how often have you used

416
417 A
418

Show Card B: next, I like to ask about medical insurance you may have had in the last 12 months.
Do you remember what you were doing on a day like today last year?
419 Did you have public or private medical insurance last year? N
If yes, go to 421
Y
420 Why

you did not have medical insurance?

|__|
417 |__ |__|
418 |__ |__|

419|__

|__|
420|__ _ __ __ __ __|

Skip to 427

421 Did you have public insurance, such as Medicare?

Did you have private insurance, such as Humana?

Did the plan cover mental health?

424

Did the plan cover vision care?

425

Did the plan cover dental care?

Did the plan cover prescribed drugs?

422

423

426

427 Do you have public medical insurance coverage today?

428 Why

If yes, go to 429

you do not have public medical insurance?

429 Do you have private medical insurance coverage today?

430 Why

421|__

you do not have private medical insurance?

RS Interview Questionnaire ENG 13-12-10

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If yes, go to next page

|__|
422|__ |__|
423|__ |__|
424|__ |__|
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426|__ |__|
427 |__ |__|
428|__ _ __ __ __ __|
429|__ |__|
430|__ _ __ __ __ __|
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Show Card B: now I like to ask about medical needs you may have had in the last 12 months, such
needing to consult a medical professional for any reason.
If you tell me that you had a medical need in the last 12 months, I will ask you if you met the need.
In the last 12 months, have you needed
Information about medical services

If yes,

Did you receive it?

Medical care for an ongoing condition

If yes,

Did you receive it?

Medical care for a sudden illness

If yes,

Did you receive it?

Medical care for a work-related accident

If yes,

Did you receive it?

Medical care for another type of accident

If yes,

Did you receive it?

To consult a medical specialist

If yes,

Did you receive it?

Surgery for a medical condition

If yes,

Did you receive it?

Mental health counseling

If yes,

Did you receive it?

Someone to talk about feeling sad

If yes,

Did you receive it?

449

Counseling for drug or alcohol abuse

If yes,

Did you receive it?

451

Someone to talk about feeling lonely

If yes,

Did you receive it?

An eye examination or care

If yes,

Did you receive it?

A dental examination or care

If yes,

Did you receive it?

If yes,

Did you receive it?

431
433

435
437
439

441
443

445
447

453
455

457 A

prescription written

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Now, I would like to ask about the number of times you were sick during the past 12 months.
In the last 12 months, how many times
459

460

__|
460|__ __|
461|__ __|
462|__ __|
463|__ __|
464|__ __|
465|__ __|

Were you sick because of your job

461

462

459|__

Were you sick with sudden illnesses

Did you have accidents at work

Did you need to see a medical doctor

463

Did you go to an emergency room

464

Were you sick but did nothing

Did you see a medical specialist such as a cardiologist

465

In the next few questions, I would like to ask about ongoing medical conditions or illnesses you
may have and medications that a doctor may have prescribed you to treat such conditions.
466 How
467 How

If 0, go to next page

many ongoing health conditions do you have

many do you treat with over-the-counter medications

468

If 0, go to next page

How many do you treat with prescribed medications

469

How many prescribed medications you should take

Show Card A: Now, I would like to ask about prescribed medications that you currently take.
How often do you...
N
I
S
F
A
470 Have prescriptions written when you need them
Purchase the prescribed medications

Find it difficult to pay for the prescribed medications

473 Not take the medications prescribed to you

471
472

RS Interview Questionnaire ENG 13-12-10

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466|__

__|
467|__ __|
468|__ __|
469|__ __|

470|__

__|
471|__ __|
472|__ __|
473|__ __|
Page 7 of 13

5.0 Physical and Mental Health

Show Card B: next, I would like to ask about preventative or annual physical and mental health
examinations you may have had in the last 12 months.
During the last 12 month, did you have a
500 Physical exam or check-up N
If not, why not?
Y
An eye examination

If not, why not?

504

A dental examination

If not, why not?

506

An exam of the colon

If not, why not?

508

A gynecological exam

If not, why not?

A self-breast exam

If not, why not?

A breast exam at a clinic

If not, why not?

A mammogram

If not, why not?

516 A prostate exam

If not, why not?

502

If a male respondent, go to 516

510
512

514

If a female respondent, go to 518

Now, I would like to ask about illnesses or conditions that a medical professional might have
diagnosed for you. I will also ask if you take medications for such illnesses or conditions.
Has a medical professional ever told you that you have
518 A hearing condition N Y If yes,
Do you take medications for it? N
520

A vision or eye condition

If yes,

Do you take medications for it?

522

A dental health condition

If yes,

Do you take medications for it?

524

An overweight condition

If yes,

Do you take medications for it?

or sugar in the blood

If yes,

Do you take medications for it?

High cholesterol

If yes,

Do you take medications for it?

Asthma condition

If yes,

Do you take medications for it?

sexually transmitted disease

If yes,

Do you take medications for it?

of any kind

If yes,

Do you take medications for it?

High blood pressure

If yes,

Do you take medications for it?

A cardiovascular condition

If yes,

Do you take medications for it?

A chronic pain condition

If yes,

Do you take medications for it?

A cancer illness or condition

If yes,

Do you take medications for it?

Any other illness or condition

If yes,

Do you take medications for it?

526 Diabetes

528
530
532 A

534 Allergy
536
538

540
542
544

Now, I would like to ask about mental health conditions that a medical professional might have
diagnosed for you. I will also ask if you take medications for such conditions.
Has a medical professional ever told you that you have
546 Attention deficit disorder N Y
If yes,
Do you take medications for it? N Y
a Depression condition

If yes,

Do you take medications for it?

An anxiety condition

If yes,

Do you take medications for it?

Schizophrenia condition

If yes,

Do you take medications for it?

Post-traumatic stress syndrome

If yes,

Do you take medications for it?

556

Problem with alcohol or drugs

If yes,

Do you take medications for it?

558

Other mental health condition

If yes,

Do you take medications for it?

548

550
552
554

RS Interview Questionnaire ENG 13-12-10

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Page 8 of 13

6.0 Health Knowledge and Practices

Show Card A: now, I would like to read a few sentences and to ask you about the frequency with
which you have thought about each one of the sentences during the last 30 days.
During the LAST MONTH, how frequently you thought that
600 Food stores are close to your home
N
I
S
F
A
Had the money to buy the food you needed

You eat as healthy as you should

Stores with healthy food choices are close to home

You had the money to buy healthy foods

You had the time to cook at home

Your body weighs as much as you should

You slept 7-8 hours every night

You physically exercised as much as you should

601

602
603

604

605
606

607
608

Smoking is not good for your health N

I
S
F
A
Show Card C: this time, I would like to ask about the number of activities related to food and
eating you might have had during the past 7 days.
During the LAST WEEK, how many
610 Meals did you have at a sit-down restaurant
609

611

Meals did you have at a fast food place

612

Meals did you have with prepared foods you brought home

613

Meals did you had with food you ordered for home delivery
614 Times
615

did you buy food items to cook at home

Times did you buy food items at a small grocery store

Times did you buy food items at a large supermarket

Now, I would like to ask about the number of health related activities you might have participated
during a typical day last week.
In a TYPICAL DAY last week, how many
617 Meals did you cook at home
616

618 Meals
619 Cigarettes
620

did you have

did you smoke

Alcoholic drinks did you have

621

Hours did you sleep

622 Minutes

did you exercise physically

Next, I would like to ask you about the people that live in this unit.
Including you, how many
623 People live in this housing unit
624

626

628

Are female

Are 65 years old or older

Are 18 years old or younger

If 0, go to Section 8.0

Of the 18 years old or younger are your own

If 0, go to Section 8.0

627

__|
601|__ __|
602|__ __|
603|__ __|
604|__ __|
605|__ __|
606|__ __|
607|__ __|
608 |__ __|
609|__ __|

610|__

__|
611|__ __|
612|__ __|
613|__ __|
614|__ __|
615|__ __|
616|__ __|

617|__

__|
618|__ __|
619|__ __|
620|__ __|
621|__ __|
622|__ __|

623|__

Are family-related
625

600|__

__|
624|__ __|
625|__ __|
626|__ __|
627|__ __|
628 |__ __|

If 1 or more, go to Section 7.0

RS Interview Questionnaire ENG 13-12-10
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Page 9 of 13

7.0 Children Module

Since you have children of your own living with you, I would like to ask about their health,
insurance coverage, and your thoughts about services the children receive at schools.
Show Card B: I will start by asking about health exams, such as yearly health exams your children
may have had last year.
During the LAST 12 MONTHS, how many of your children had
Immunizations up-to-date

700|__

__|

A physical exam or check up

701|__

__|

eye exam

702|__

__|

dental exam

703|__

__|

704|__

__|

700
701

702 An
703 A

Show Card A: Now, I would like to ask about the ways you pay for your children medical services
such as visits to doctors, or medical exams.
How often do you pay for your children medical services with
704 Cash, check, or debit card N
I
S
F
A
A credit card

705|__

__|

Private insurance, such as Blue Cross

706|__

__|

707 Public

707|__

__|

708|__

__|

709|__

__|

705
706

708

insurance, such as All Kids

If all, skip and Show Card B

How many children are covered with All Kids

709 Do
710

you know about All Kids program

Have you applied to All Kids program

If No, skip and Show Card B

710|__

__|

Was an All Kids application denied

If No, skip and Show Card B

711|__

__|

712|__

__|

713|__

__|

711

712 Why

was the application denied

Show Card B: Now I would like to ask about food and medical services your children might have
receive at school in the last 12 months.
During LAST YEAR, how many of your children
713 Attended any type of school
If 0, skip to next page
714 Attended

a charter school

714|__

__|

715 Attended

a private school

715|__

__|

a public school

716|__

__|

breakfast at school

717|__

__|

lunch at school

718|__

__|

medical services at school

719|__

__|

716 Attended
717 Had

718 Had
719 Received

Show Card A: Now I would like to ask about the services offered at schools.
During the LAST YEAR, how often have you thought that,
720 Breakfasts at schools included healthy food items N
I
S

720|__

__|

Lunches at schools included healthy food items

721|__

__|

Medical services at schools were adequate

722|__

__|

The physical exercise children have at school was adequate

723|__

__|

724|__

__|

721

722
723

724 The

safety of children at schools was adequate

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Page 10 of 13

8.0 Demographic Information

In the last few questions, I would like a few questions about you.
What is your gender identification?
801 What is your current marital status?
800

Female 1

Male 2

GLBT 3

Other 4

Divorced 1

Civil union 2

Free union 3

Married4

Never married 5

Separated 6

Widow(er) 7

Other 8

800|__

__|

801|__

__|

802|__

__|

Show Card D: Now I would like to ask about the population categories that you choose while
filling-out forms. I will ask if you identify as Hispanic and with the seven racial groups.
802
803

Do you identify as Hispanic or Latino?

With which racial category do you identify?

804
805

Alaskan Native 1

Asian American 2

African American 3

Native American 4

White 5

Multiple races 6

None 7

Other 8

803|__

__|
804|__ __|

How many years of formal education have you completed ?

If 0, go to 807

How many years of technical trainings have you completed?

806 What

kind of training did you complete?

807 What is your current employment status

Employed 1

How many months have you been unemployed?

809 In the past year, how many months did you work?
810 In

the past year, how many paid jobs did you have?

811 In the past, what kind of paid job(s) have you had?
In a typical week, how many days do you work?

812
813

In a typical week, how many hours do you work?

814

In general, how frequently did your get paid?

815

In general, how do you receive your salary?

Daily 1

Weekly 2

Monthly 4

Other 5

Cash 1
Other 4

816

What is the typical amount of a paycheck?

__ __ __ __|

807|__

__|

808|__

__|
809|__ __|
810|__ __|
811|__ __ __ __ __|
812|__ __|
813|__ __|

Direct deposit 2

814|__

__|

815|__

__|

816|__

__ __ __|

817|__

__|
__ __ __|

Check 3

If cash, go to 817

What was the lowest rate per hour you have earned?

818|__

What was the highest rate per hour you have earned?

819|__

818
819

806|__

Biweekly 3

817 Where taxes withheld from your salary?

__|

Unemployed 3

If employed, go to 809
If retired, go to 820
If more than 12, go to 811

Other 4
808

Retired 2

805|__

__ __ __|
820|__ __ __ __ __|
821|__ __ __ __ __|

820 What is your native language

821

What is the main language you speak at home?

822

823
824 What

822|__

What other languages do you speak at home?

What year were you born?

year were you discharged from military service?

825

What is your country of origin?

Enter 0, if no service
If NOT the U.S., go to Section 9.0

If the U.S., conclude the survey

On behalf of the research partners, I thank you for your time and for your collaboration.
826 Ending time
:
RS Interview Questionnaire ENG 13-12-10
www.chana-project.org/chana2014/

__ __ __ __|
823|__ __ __ __|
824|__ __ __ __|
825|__ __|

826

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Page 11 of 13

9.0 Immigrant Module

Since you were not born in the U.S., I would like to ask about health practices here in the U.S. and
in your country of origin.
900 From which province or state are you from

900|__

__ __ __ __|

which city or town are you from

901|__

__ __ __ __|

year did you enter the U.S. for the first time

902|__

__ __ __ __|

901 From
902 What

Now I would like to ask about contacts you may have with relatives in your country of origin.
903

How many close relatives do you have in your country

904 In

a month, how many times do you talk to your relatives

905

__|
904|__ __|
If 0, go to Show Card A 905|__ __|
906|__ __ __ __|
907|__ __|
908|__ __ __ __|
If 0, go to Show Card A

In a month, how many times do you send money to your relatives

906

907 How

On average, how much money do you send each time $

many days ago did you sent money home the last time
908 How

much money did you send home the last time $

903|__

Show Card A: Now I would like to ask about what you may do when you get sick here in the U.S.
When you are sick here, how often do you

Consult with relatives in your country

909|__

__|

Consult traditional professionals in your country

910|__

__|

Have traditional medicines sent from your country

911|__

__|

Buy in the U.S. traditional medicines from your country

912|__

__|

Consult a medical professional at your country

913|__

__|

Have medicines sent from your country

914|__

__|

Buy in the U.S. western medicines made in your country

915|__

__|

916|__

__|

917|__

__|

909
910
911
912

913

914
915

Now I will ask about health practices that you may carry out while visiting your home country.
916 Since
917 In

If 0, conclude survey

in the U.S., how many times have you visited your country

a typical year, how many times do you visit your country

While visiting your home country, how often do you use the opportunity to
See a traditional medicine professional

918|__

__|

See a western medicine professional

919|__

__|

920

See a western medical specialist

920|__

__|

921

Have medical procedures done

921|__

__|

See a dental medical professional

922|__

__|

See an ophthalmologist or eye medical professional

923|__

__|

Purchase traditional medicines to bring to the U.S.

924|__

__|

Purchase western medicines to bring to the U.S.

925|__

__|

918

919

922
923

924

925

On behalf of the research partners, I thank you for your time and for your collaboration.
926
RS Interview Questionnaire ENG 13-12-10
www.chana-project.org/chana2014/

Ending time

926

|__|__|__|__|

Page 12 of 13

COMMUNITY HEALTH ASSETS AND NEEDS ASSESSMENT

For more information about the CHANA 2011-2014 Study,
visit http://www.chana-project.org/chana2014/

__________________________________________________________________