Healthcare Access Disparities Survey
Help us understand the challenges in healthcare access across communities.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Age Group
*
Please Select
Under 18
18-24
25-34
35-44
45-54
55-64
65 and above
Gender Identity
*
Please Select
Female
Male
Non-binary
Prefer not to say
Location/Region (State, Province, or Area)
*
Please Select
Option 1
Option 2
Option 3
Ethnicity/Race
*
Please Select
Hispanic or LatinX
White
Black or African American
Asian
Native American or Alaska Native
Native Hawaiian or Pacific Islander
Other
Type of Healthcare Facility Usually Accessed
*
Please Select
Public Clinic
Private Hospital
Community Health Center
Urgent Care
Other
Have you experienced barriers in accessing healthcare services in the past year?
*
Yes
No
If yes, please specify the main barriers faced (e.g., transportation, cost, language, wait times, etc.)
Difficulty in Accessing Healthcare Due To Language Barriers
*
Please Select
No difficulties
Minor difficulties
Major difficulties
Availability of Healthcare Providers in Your Area
*
Please Select
Highly Sufficient
Adequate
Limited
Very Limited
On a scale of 1 to 10, how would you rate your overall experience with healthcare access?
*
Poor
1
2
3
4
5
6
7
8
9
Excellent
10
1 is Poor, 10 is Excellent
Submit
Should be Empty: