Home

About Us
       Staff Directory
       Board of Health Members
       Public Health Plan

Services
       AIDS Division
       Air Pollution
          Air Quality Index
       Environmental Health
       Nursing Division
          Well Child Clinic
          Immunization Only Clinics
          Infant Immunization Initiative
          Communcable Disease Control
          Sexually Transmitted Disease (STD)
          HIV Counseling & Testing
       Vital Statistics

Health Links

Calendar

Contact Us

Stats/Reports

Health Updates

Forms
       Air Pollution Complaint Form
       Complaint Form

Office on Minority Health
       Home
       About Us
       Information on Health
       Staff
       Events
       Minority Health Month
       Minority Health Month Event Dates
       Survey

Health Needs Questionnaire

In order to better serve the population, the Youngstown Office on Minority Health is asking you to complete this short survey. The data will be analyzed by our partner the Youngstown State University’s Center for Human Services Development.

1. Do you have health insurance? :

3. What are the health needs of the people in the household:

4. Race/Ethnicity:

5. Zip Code:

6. Please select your age range:

7. Number of people in the household including yourself.

Under 18 Years Old:

Over 18 Years Old:

Submit

©2010 Youngstown City Health District. All rights reserved.
Powered by CBOSS ArchITech CMS	Login