Heat Health Equity Assessment Questionnaire Form
Assess heat-health equity conditions, exposure barriers, and priority needs in a community or population. Do not include sensitive personal or health-identifying information.
Assessment Scope and Context
Your role or perspective
*
Resident
Community worker
Public health staff
Clinician
Local government staff
Researcher
Other
Primary location or neighborhood being assessed
*
Main heat-health concern or exposure context
*
Heat Exposure and Equity Conditions
Heat-related conditions and equity impacts
*
Rows
Strongly disagree
Disagree
Neutral
Agree
Strongly agree
People in this context are regularly exposed to extreme heat.
1
2
3
4
5
Access to cooling options is limited for those most at risk.
6
7
8
9
10
Housing conditions make heat exposure worse for some groups.
11
12
13
14
15
There are barriers to seeking relief during extreme heat (e.g., cost, mobility, transportation, or service access).
16
17
18
19
20
Overall severity of heat-related inequity
*
1
2
3
4
5
Most affected group or population segment
*
Older adults
Infants and young children
Outdoor workers
People experiencing homelessness
Low-income households
People with disabilities
Other
Briefly describe any additional heat-related equity impacts observed
Needs, Priorities, and Follow-up
What is the top intervention priority?
*
Cooling centers
Tree canopy and shade
Utility bill assistance
Emergency outreach for older adults
Home cooling assistance
Community education and outreach
Other
Recommended actions, resources, or community support needs
*
How confident are you in this assessment?
Not confident
1
2
3
4
5
6
7
8
9
Very confident
10
1 is Not confident, 10 is Very confident
Submit
Should be Empty: