The code block below illustrates how one might use # and // as comments in your logic and calculations.

This value you provided is not a number. Please try again.

This value you provided is not an integer. Please try again.

The value entered is not a valid Vanderbilt Medical Record Number (i.e. 4- to 9-digit number, excluding leading zeros). Please try again.

The value you provided must be within the suggested range

The value you provided is outside the suggested range

This value is admissible, but you may wish to double check it.

The value entered must be a time value in the following format HH:MM within the range 00:00-23:59 (e.g., 04:32 or 23:19).

This field must be a 5 or 9 digit U.S. ZIP Code (like 94043). Please re-enter it now.

This field must be a 10 digit U.S. phone number (like 415 555 1212). Please re-enter it now.

This field must be a valid email address (like joe@user.com). Please re-enter it now.

The value you provided could not be validated because it does not follow the expected format. Please try again.

Required format:

yQUwqPhFg2HVHga66xFJ28hDIrQRmcNRybm6JtUY4dihJEpkJUhYnDPscGr9yz

COHIT Community Health Survey

We are looking to better understand ways that we can serve our community.

Please take this 10 minute survey.

Buscamos comprender mejor las formas en que podemos servir a nuestra comunidad.

Responda esta encuesta de 10 minutos.

Thank you!

Would you like to continue in English or Spanish?
¿Quiere continuar en español o en inglés?

English / inglés

Spanish / español

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Central Oklahoma Community Health Impact Team (COHIT)
Community Health Survey
Respondent Information Form

Why is this survey being done? The purpose is to learn more about the health needs in the community.
How many people will take part in this survey? We hope to get opinions from as many community members as possible.
What are the risks, benefits, and options of the survey? There are no risks or specific benefits to you for participating. You will be given the opportunity to voice your experiences and suggestions. You may choose not to participate.
What about confidentiality? You will not be asked to provide your name, email, or any other identifiable information in this survey. The information you provide will not be linked to information you have provided for the vaccine.
What are my rights as a participant? Taking part in this survey is voluntary. You may choose not to take part or may stop answering questions at any time.
Whom do I contact if I have questions? If you have any questions about the survey, you may contact us at COHITsurvey@gmail.com
Your participation in the survey signifies your consent.

Please click "agree" below to continue with the survey or "Do not agree" to end the survey.

Agree

Do not agree (END SURVEY)

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Central Oklahoma Community Health Impact Team (COHIT)

Encuesta de Salud Comunitaria

Formulario de Consentimiento

¿Por qué se realiza esta encuesta? El propósito es aprender más sobre las necesidades de salud en la comunidad.

¿Cuántas personas participarán en esta encuesta? Esperamos obtener opiniones de tantos miembros de la comunidad como sea posible.

¿Cuáles son los riesgos, beneficios y opciones de la encuesta? No hay riesgos ni beneficios específicos para usted por participar. Se le dará la oportunidad de expresar sus experiencias y sugerencias. Puede optar por no participar.

¿Y la confidencialidad? No se le pedirá que proporcione su nombre, correo electrónico o cualquier otra información identificable en esta encuesta. La información que proporcione no estará vinculada a la información que haya proporcionado para la vacuna.

¿Cuáles son mis derechos como participante? La participación en esta encuesta es voluntaria. Puede optar por no participar o dejar de responder preguntas en cualquier momento.

¿Con quién me comunico si tengo preguntas? Si tiene alguna pregunta sobre la encuesta, puede contactarnos en COHITsurvey@gmail.com

Su participación en la encuesta significa su consentimiento.

* must provide value

Estar de acuerdo

No estoy de acuerdo (finalizar encuesta)

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Are you...

Less than 18,

18 to 24,

25 to 34,

35 to 44,

45 to 54,

55 to 64, or

Over 65 years of age?

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Tiene usted...

Menos de 18 años

18 a 24,

25 a 34,

35 a 44,

45 a 54,

55 a 64, o

Más de 65 años

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You have selected an option that triggers this survey to end right now.

To save your responses and end the survey, click the 'End Survey' button below. If you have selected the wrong option by accident and/or wish to return to the survey, click the 'Return and Edit Response' button.