Once you've identified the leaders of the community, it's time to ask them what they perceive to be the problems and needs of the community. This sample survey would be appropriate for a community who is interested in starting a heart disease prevention program. The focus of the survey can be changed to meet the objectives of your organization. When completed, the records can be an invaluable reference tool for future projects and programs.
- In your opinion what factors contribute to the high rate of heart disease in your community?
- What do you think should be done to address heart disease problems more effectively in this area?
- What barriers, if any, do you see to implementing a project to prevent heart disease in our community?
(If none, skip to question 5.)
- What strategies would you suggest for overcoming these barriers?
- What role could you play to help us implement this project in our community?
(Do not read out the choices below. Use them as suggestions and as a guide for recording responses.)
- Serve on a coalition
- Serve on a task force or committee
- Public endorsement/testimonial
- Appoint a person to work on the project
- Donate resources, i.e., meeting space, advertising, personnel, funds, etc.
- Could you suggest other organizations/groups in our community who could take part in this project?
- Who in our community would you consider critical to the success of this project?
- Are there any other suggestions or ideas that you can give me as we prepare to get this project started?
- Are there any questions you would like to ask me?
Thank you for your time and support. I'll be in touch with you again to let you know how the project is progressing and how you can best help to ensure the project's success.
Reprinted From: Florence Heart to Heart Program,South Carolina Cardiovascular Disease Prevention Project
- Where do you usually go for health information?
- Where do you go for your health services? (non-emergency services)
- From the list below, please choose the three areas that you believe should receive more emphasis in the community than they do now? (Choose only 3 and rank them from 1 being the most serious to 3 being the least serious.)
- From the list below, choose three areas that you believe should receive less emphasis in the community than they do now. (Check only 3.)
- What specific health care and health education services are most needed in our community?
- How could the existing health services be improved?
Keep records of the leaders you interview to ensure that you are getting input from different segments of the community. Try to record this demographic information on the respondent, without directly asking the questions. This information should be kept confidential and should not be attached to the survey or final report.
- Respondent's name
- Sex (M/F)
- Affiliation that resulted in respondent being selected for the survey
- Length of time the respondent has been a member of the community
(<3 years, 3-10 years, >10 years)
- Optional: In what town/neighborhood/school district/etc. does the respondent live?