Anonoymous SURVEY

for Health and Human Services so that we may better understand your needs.
This survey should take less than one minute of your time.

Have you ever been seen or visited by a Community Health Representative?

Yes

No

I don’t know what that is

Would you use a Community Health Representative who will help you understand or address your health needs through free home visits, rides to doctor appointments, educational events and emergency transport assistance?

Probably

Probably not

I don’t know

When using Indian Health Service, have you ever used Contract Health Services (sent to a private doctor outside of IHS)?

Yes

No

If you were denied for IHS Contract Health Services, what was the reason?

I was not denied

I was not qualified

Funding ran out

I was not a priority

I don't know why I was turned down

If you were denied a referral through HIS Contract Health Services did you?

I was not denied

Still waiting for a referral

Eventually got a referral after some time

Go to a private doctor on your private insurance

Go to another Indian Health Service outside your usual hospital

If the UKB Tribe had to pay for its own programs which to you consider the most important?

Community Health Representative

Contract Health Services

Both

Undecided

Are you?

Male

Female

I'd rather not say

Are you a senior?

Yes

No

I'd rather not say

Which district do you live in?

UKB HHS Sf 11.03.12