Northwest Wisconsin Community Health Center
Planning Project
Community Health Center
Consumer Survey
1. Do you (and your family if applicable) currently have
medical insurance or health care coverage?
Yes No
Don’t Know
If yes, how is this coverage currently being provided?
Health insurance provided by my employer.
Health insurance I or my family members purchase.
Badger Care provided by the State of Wisconsin.
Medicare
Veteran’s Administration
Other (including pension benefit)
2. What is your deductible?
3. Do you (and your family if applicable) have dental
insurance?
Yes No
Don’t Know
4. How many family members live in your immediate
household?
5. Would you rate your own personal health as being:
Excellent Good
Fair Poor
Don’t Know
6. Do you or members of your family have problems
finding health care providers in your community when you
need services?
Yes No Don’t
Know
7. Have you experienced any problems during the past
five years in paying for your medical bills?
Yes No
Don’t Know
NW CEP Community Health Center Consumer Survey - Page
2
7. Have you seen a dentist in the last 12 months?
Yes No Don’t
Know
If No, Why?
8. In your opinion, what are the greatest health
problems in the community in which you live?
9. Do you believe that a community health center that
would charge for its services based on the patient’s or
family’s income and ability to pay would be a good idea?
Yes No Don’t Know
10. If a Community Health Center were established to
serve Ashland and Bayfield Counties would you and your
family members use it?
Yes No Don’t Know
11. What is your average yearly household income?
Less that $15,000 per year
$15,000 to $29,999 per year
$30,000 to $50,000 per year
More than $50,000 per year
12. What is your Zip Code?
THANKS FOR PARTICIPATING
IN THE NORTHWEST WISCONSIN
COMMUNITY HEALTH CENTER PLANNING SURVEY
