1. Welcome! Tell us about you!
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1 1. Welcome! Tell us about you! Thank you for taking the time to fill out this survey! It should take no more than 10 minutes of your time. The purpose of this survey is to assess your needs and desire for a faith based partnership between your Boston faith based community and the Boston Public Health Commission. The information collected will be used to inform the process for this initiative in a way we hope will be beneficial for all those involved. Your individual responses and contact information will not be shared without your permission. If a question is not starred, you may skip it if you don't feel comfortable answering. 1. Demographic Information Name of Faith Based Organization: Location of Faith Based Organization: Mailing Address of Faith Based Organization: Neighboorhood: Zip: 2. Describe your role in your Faith Based community. Volunteer Employed Title/Role (e.g. Member, Administrator, Pastor, Rabbi, etc.) Page 1
2 3. Do you have a medical background? No Yes (please specify) 2. Tell us about your Faith Based community's interests Does your Faith Based Community have a Wellness Center? Yes No If No, would your Congregation benefit from a Wellness Center? 5. Does your Faith Based community participate in or host health screenings or health fairs? Not Sure No Yes, (Please specify who or what organizations have hosted your health screenings or health fairs) 6. Are there any support groups within your Faith based community(choose all that apply from the list below)? Caregiver support Weight Management/Nutrition Grief Support Cancer Domestic Violence Substance Abuse (Drugs and/or Alcohol) Parenting Support 3. Tell us more about your organization... Page 2
3 7. What are the ethnic/cultural populations that attend your faith based community(please choose all that apply)? African Hispanic/Latinos Portuguese African American Chinese White West Indian/Caribbean Vietnamese Haitian Cape Verdian 8. What are the Primary Languages spoken in your faith based community? English French Chinese (Mandarin) Spanish Portuguese Chinese (Cantonese) Haitian Creole Cape Verde Creole Vietnamese 9. What is the number of attendees during services in your faith based community? Less than or more 4. How can we best collaborate? 10. Would you, or someone from your faith based community, like to partner with the Boston Public Health Commission on public health issues and concerns within your neighborhood? Yes No Maybe Page 3
4 11. Please rate the topics by how interested your community is in collaborating or addressing these health concerns. Not Interested Somewhat Interested Very Interested Health Insurance/Health Care Access Men s Health Women s Health Mental Health Exercise/Weight Loss Domestic Violence CPR/First Aid Parenting Sexuality Nutrition Stress Management Infectious Diseases (flu, TB, HIV, etc.) Child/Adolescent Health Pregnancy Cancer Asthma Diabetes Tobacco Cessation Oral Health Substance Abuse Immunizations Environmental Health Health Inequity 12. Do you have any other ideas or suggestions about collaboration opportunities? 5 6 Page 4
5 13. What day would be most convenient for your Faith Based Organization's contact person to attend meetings or events hosted by BPHC? Mornings 8am 12pm Afternoons 12pm 4pm Evenings 4pm 8pm Monday Tuesday Wednesday Thursday Friday Saturday Sunday Additional comments 5. Please tell us more Information of the contact person for your Faith Based Organization Name: Address: Address 2: City/Town: State: 6 ZIP/Postal Code: Address: Phone Number (xxx xxxxxxx): 6. Thank You! 15. We really want to thank you for taking the time to fill out this survey. Please use this space for any additional comments or suggestions for the Faith Based Partnership Initiative. 5 6 Page 5
6 16. Please list the information of any other person in your faith based community that we should contact. Name: Phone: Address: If you have any additional questions, please contact: Triniese Polk, Outreach Director, BPHC 1010 Mass Ave, Boston Page 6
Name: Address: City: State: Zip: Phone: Cell: Work: Fax: Best time to call: Reference (Name and or phone):
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