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Submitted URL: https://na0.icarol.com/s?16OSD6
Effective URL: https://na0.icarol.com/pub/SurveyForm.aspx?org=68601&key=a60622d8-e8c2-42b3-9ce9-f7062630efa5
Submission: On June 24 via manual from US — Scanned from CA
Effective URL: https://na0.icarol.com/pub/SurveyForm.aspx?org=68601&key=a60622d8-e8c2-42b3-9ce9-f7062630efa5
Submission: On June 24 via manual from US — Scanned from CA
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<h2 id="Page-Title"></h2>
<h1 id="welcome-message">If you SUBMITTED this survey already, please do not complete it again. <br> ▪You can answer these questions any way you want. <br> ▪You can choose not to answer a question. <br> ▪Your answers are not connected to your
call record. <br> ▪Your answers will not negatively impact your services or ability to receive benefits in any way. <br><br> Northwest Human Services shares de-identified data from this survey with our funders, including the Oregon Health
Authority.<br><br> Thank you for your time! </h1>
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<div class="div-category"><span id="CategoryName119623" class="category-name">Race, Ethnicity, Language and Disability<br></span><span id="GroupName552852"
title="We would like to know your race, ethnicity, language and disability background so that we can find and address unfair health and service differences. You are free to choose &quot;Don&#39;t Know/Unknown&quot; or &quot;Don&#39;t Want to Say.&quot;"
class="question-name"><br>We would like to know your race, ethnicity, language and disability background so that we can find and address unfair health and service differences. You are free to choose "Don't Know/Unknown" or "Don't Want
to Say."<br></span><span id="GroupName552853" class="question-name" groupname="In your own words, how would you identify your <strong>race, ethnicity, tribal affiliation, country of origin, or ancestry?"><label
for="cphBody_552853"><br>In your own words, how would you identify your <strong>race, ethnicity, tribal affiliation, country of origin, or ancestry?<br></strong></label></span><textarea name="552853" rows="2" cols="20" id="552853"
tabindex="35" class="UserInput" grouprequired="false" style="height:50px;width:300px;"></textarea><strong><span id="SpacerAfterTextBox552853"><br></span><span id="GroupName552854" class="question-name"
groupname="Which of the following describes your racial or ethnic identity?"><label for="cphBody_cbl552854"><br>Which of the following describes your racial or ethnic identity?<img title="Required"
onmouseover="this.style.cursor='pointer';" src="../../images/icon_asterisk.png" alt="Required" style="height:7px;width:7px;border-style: none;"><br></label></span>
<ul id="cbl552854" class="UserInput" grouprequired="true">
<li><span fieldname="American Indian, Alaska Native or Indigenous Peoples of Canada, Mexico, Central or South America"><input id="cbl552854_0" type="checkbox" name="cbl552854$0" tabindex="35" value="2540211"><label
for="cbl552854_0">American Indian, Alaska Native or Indigenous Peoples of Canada, Mexico, Central or South America</label></span></li>
<li><span fieldname="Hispanic and Latino/a/x"><input id="cbl552854_1" type="checkbox" name="cbl552854$1" tabindex="35" value="2540212"><label for="cbl552854_1">Hispanic and Latino/a/x</label></span></li>
<li><span fieldname="Native Hawaiian and Pacific Islander"><input id="cbl552854_2" type="checkbox" name="cbl552854$2" tabindex="35" value="2540213"><label for="cbl552854_2">Native Hawaiian and Pacific Islander</label></span></li>
<li><span fieldname="Black and African American"><input id="cbl552854_3" type="checkbox" name="cbl552854$3" tabindex="35" value="2540214"><label for="cbl552854_3">Black and African American</label></span></li>
<li><span fieldname="Asian"><input id="cbl552854_4" type="checkbox" name="cbl552854$4" tabindex="35" value="2540215"><label for="cbl552854_4">Asian</label></span></li>
<li><span fieldname="Middle Eastern/ North African"><input id="cbl552854_5" type="checkbox" name="cbl552854$5" tabindex="35" value="2540216"><label for="cbl552854_5">Middle Eastern/ North African</label></span></li>
<li><span fieldname="White"><input id="cbl552854_6" type="checkbox" name="cbl552854$6" tabindex="35" value="2540217"><label for="cbl552854_6">White</label></span></li>
<li><span fieldname="Other"><input id="cbl552854_7" type="checkbox" name="cbl552854$7" tabindex="35" value="2540218"><label for="cbl552854_7">Other</label></span></li>
<li><span fieldname="Don''''t Know"><input id="cbl552854_8" type="checkbox" name="cbl552854$8" tabindex="35" value="2540219"><label for="cbl552854_8">Don't Know</label></span></li>
<li><span fieldname="Don''''t Want to Say"><input id="cbl552854_9" type="checkbox" name="cbl552854$9" tabindex="35" value="2540220"><label for="cbl552854_9">Don't Want to Say</label></span></li>
</ul><span id="GroupName552855" class="question-name"><br>
<div> Now we ask about specific identities.</div>
<br>
</span><span id="GroupName552856" class="question-name" groupname="If you checked more than one category above, is there one you think of as your primary racial or ethnic identity?"><label for="cphBody_552856"><br>If you checked more
than one category above, is there one you think of as your primary racial or ethnic identity?<img title="Required" onmouseover="this.style.cursor='pointer';" src="../../images/icon_asterisk.png" alt="Required"
style="height:7px;width:7px;border-style: none;"><br></label></span><select name="552856" id="552856" tabindex="35" class="UserInput" grouprequired="true" style="width:515px;">
<option value="-1">(select one)</option>
<option value="2540221">N/A -- Not applicable. I did not check</option>
<option value="2540222">Yes. There is ONE racial or ethnic identity that I think of as PRIMARY.</option>
<option value="2540223">No. I identify as Biracial or Multiracial I do not have just one primary racial or ethnic identity</option>
<option value="2540224">Don't Know</option>
<option value="2540225">Don't Want to Answer</option>
</select><span id="SpacerAfterDropDownList552856"><br></span><span id="GroupName574514" class="question-name" groupname="What languages do you use at home?"><label for="cphBody_574514"><br>What languages do you use at
home?<br></label></span><input name="574514" type="text" id="574514" tabindex="35" class="UserInput" grouprequired="false" style="width:70px;"><span id="SpacerAfterTextBox574514"><br></span><span id="GroupName574525"
class="question-name" groupname="We are hoping to offer services in additional languages. What is the ONE language you most prefer to use when communicating with us BY TEXT?"><label for="cphBody_574525"><br>We are hoping to offer
services in additional languages. What is the ONE language you most prefer to use when communicating with us BY TEXT?<br></label></span><input name="574525" type="text" id="574525" tabindex="35" class="UserInput"
grouprequired="false" style="width:70px;"><span id="SpacerAfterTextBox574525"><br></span><span id="GroupName574526" class="question-name"
groupname="We are hoping to offer services in additional languages. Please write-in the ONE language you most prefer to use when communicating with us BY PHONE?"><label for="cphBody_574526"><br>We are hoping to offer services in
additional languages. Please write-in the ONE language you most prefer to use when communicating with us BY PHONE?<br></label></span><input name="574526" type="text" id="574526" tabindex="35" class="UserInput"
grouprequired="false" style="width:70px;"><span id="SpacerAfterTextBox574526"><br></span><span id="GroupName552857" class="question-name" groupname="What is your gender?"><label for="cphBody_552857"><br>What is your
gender?<br></label></span><select name="552857" id="552857" tabindex="35" class="UserInput" grouprequired="false" style="width:515px;">
<option value="-1">(not applicable)</option>
<option value="2540226">Woman/Girl</option>
<option value="2540227">Man/Boy</option>
<option value="2540228">Agender/ No gender</option>
<option value="2540229">Non-binary</option>
<option value="2540230">Questioning</option>
<option value="2540231">Don't know</option>
<option value="2540232">I don't know what this question is asking</option>
<option value="2540233">I don't want to answer</option>
</select><span id="SpacerAfterDropDownList552857"><br></span><span id="GroupName552858" class="question-name" groupname="Are you transgender?"><label for="cphBody_552858"><br>Are you transgender?<br></label></span><select
name="552858" id="552858" tabindex="35" class="UserInput" grouprequired="false" style="width:515px;">
<option value="-1">(not applicable)</option>
<option value="2540234">Yes</option>
<option value="2540235">No</option>
<option value="2540236">I don't know what this question is asking</option>
<option value="2540237">I don't want to answer</option>
<option value="2540238">Don't know</option>
</select><span id="SpacerAfterDropDownList552858"><br></span><span id="GroupName552859" class="question-name" groupname="How do you describe your sexual orientation or sexual identity?"><label for="cphBody_552859"><br>How do you
describe your sexual orientation or sexual identity?<br></label></span><select name="552859" id="552859" tabindex="35" class="UserInput" grouprequired="false" style="width:515px;">
<option value="-1">(not applicable)</option>
<option value="2540239">Same-sex loving</option>
<option value="2540240">Same-gender loving</option>
<option value="2540241">Lesbian</option>
<option value="2540242">Gay</option>
<option value="2540243">Bisexual</option>
<option value="2540244">Straight (attracted mainly to or only to other gender(s))</option>
<option value="2540245">Pansexual</option>
<option value="2540246">Asexual</option>
<option value="2540247">Queer</option>
<option value="2540248">Questioning</option>
<option value="2540249">Don't know</option>
<option value="2540250">I don't know what this question is asking</option>
</select><span id="SpacerAfterDropDownList552859"><br></span><span id="GroupName552860" class="question-name" groupname="Enter your age"><label for="cphBody_552860"><br>Enter your age<br></label></span><input name="552860" type="text"
id="552860" tabindex="35" class="UserInput" grouprequired="false" style="width:70px;"><span id="SpacerAfterTextBox552860"><br></span><span id="GroupName552861" class="question-name" groupname="What is your zip code?"><label
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id="SpacerAfterTextBox552861"><br></span><span id="GroupName552862" class="question-name"
groupname="Have you ever served on active duty in ANY branch of the military (Army, Navy, Air Force, Marine Corps, Coast Guard, National Guard or Reserves)?"><label for="cphBody_552862"><br>Have you ever served on active duty in ANY
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<option value="-1">(not applicable)</option>
<option value="2540251">Yes, I am currently on active duty</option>
<option value="2540252">Yes, I have served in the past</option>
<option value="2540253">No, Never on active duty except for basic/military Training</option>
<option value="2540254">No, Never on active duty</option>
</select><span id="SpacerAfterDropDownList552862"><br></span><span id="GroupName552863" class="question-name"
groupname="In the past year, have you or any family members you live with been unable to get any of the following when it was really needed?"><label for="cphBody_cbl552863"><br>In the past year, have you or any family members you
live with been unable to get any of the following when it was really needed?<br></label></span>
<ul id="cbl552863" class="UserInput" grouprequired="false">
<li><span fieldname="Food"><input id="cbl552863_0" type="checkbox" name="cbl552863$0" tabindex="35" value="2540255"><label for="cbl552863_0">Food</label></span></li>
<li><span fieldname="Utilities"><input id="cbl552863_1" type="checkbox" name="cbl552863$1" tabindex="35" value="2540256"><label for="cbl552863_1">Utilities</label></span></li>
<li><span fieldname="Medicine or any health care need (Medical, Dental, Mental Health, Vision)"><input id="cbl552863_2" type="checkbox" name="cbl552863$2" tabindex="35" value="2540257"><label for="cbl552863_2">Medicine or any health
care need (Medical, Dental, Mental Health, Vision)</label></span></li>
<li><span fieldname="Phone"><input id="cbl552863_3" type="checkbox" name="cbl552863$3" tabindex="35" value="2540258"><label for="cbl552863_3">Phone</label></span></li>
<li><span fieldname="Reliable home internet"><input id="cbl552863_4" type="checkbox" name="cbl552863$4" tabindex="35" value="2540259"><label for="cbl552863_4">Reliable home internet</label></span></li>
<li><span fieldname="School books or supplies"><input id="cbl552863_5" type="checkbox" name="cbl552863$5" tabindex="35" value="2540260"><label for="cbl552863_5">School books or supplies</label></span></li>
<li><span fieldname="Clothing"><input id="cbl552863_6" type="checkbox" name="cbl552863$6" tabindex="35" value="2540261"><label for="cbl552863_6">Clothing</label></span></li>
<li><span fieldname="Child Care"><input id="cbl552863_7" type="checkbox" name="cbl552863$7" tabindex="35" value="2540262"><label for="cbl552863_7">Child Care</label></span></li>
<li><span fieldname="Safe and stable housing"><input id="cbl552863_8" type="checkbox" name="cbl552863$8" tabindex="35" value="2540263"><label for="cbl552863_8">Safe and stable housing</label></span></li>
<li><span fieldname="Transportation"><input id="cbl552863_9" type="checkbox" name="cbl552863$9" tabindex="35" value="2540264"><label for="cbl552863_9">Transportation</label></span></li>
</ul><span id="GroupName552864" class="question-name" groupname="What kinds of health insurance or health care coverage do you have?"><label for="cphBody_552864"><br>What kinds of health insurance or health care coverage do you
have?<img title="Required" onmouseover="this.style.cursor='pointer';" src="../../images/icon_asterisk.png" alt="Required" style="height:7px;width:7px;border-style: none;"><br></label></span><select name="552864" id="552864"
tabindex="35" class="UserInput" grouprequired="true" style="width:515px;">
<option value="-1">(select one)</option>
<option value="2540271">Children’s Health Insurance Program (CHIP)</option>
<option value="2540275">Don’t Know</option>
<option value="2540267">Indian Health Service</option>
<option value="2540270">Medicaid</option>
<option value="2540268">Medigap</option>
<option value="2540266">Military related health care: TRICARE (CHAMPUS)/VA health care/CHAMPVA Medicare</option>
<option value="2540273">No coverage of any type</option>
<option value="2540272">Other government program</option>
<option value="2540265">Private health insurance (Employer or Individual Plan)</option>
<option value="2540274">Refused</option>
<option value="2540269">State-sponsored health plan (Oregon Health Plan)</option>
</select><span id="SpacerAfterDropDownList552864"><br></span><span id="GroupName552865" class="question-name"><br>
<div>
<strong>The next questions ask about functional limitations.</strong><br>
</div>
<div> There are no 'right' answers</div>
<br>
</span><span id="GroupName552866" class="question-name" groupname="Are you deaf or do you have serious difficulty hearing?"><label for="cphBody_552866"><br>Are you deaf or do you have serious difficulty hearing?<img title="Required"
onmouseover="this.style.cursor='pointer';" src="../../images/icon_asterisk.png" alt="Required" style="height:7px;width:7px;border-style: none;"><br></label></span><select name="552866" id="552866" tabindex="35" class="UserInput"
grouprequired="true" style="width:515px;">
<option value="-1">(select one)</option>
<option value="2540276">Yes</option>
<option value="2540277">No</option>
<option value="2540278">No</option>
<option value="2540279">Don't Know</option>
<option value="2540280">Don't Want to Say</option>
</select><span id="SpacerAfterDropDownList552866"><br></span><span id="GroupName552868" class="question-name" groupname="Are you blind or do you have serious difficulty seeing, even when wearing glasses?"><label
for="cphBody_552868"><br>Are you blind or do you have serious difficulty seeing, even when wearing glasses?<img title="Required" onmouseover="this.style.cursor='pointer';" src="../../images/icon_asterisk.png" alt="Required"
style="height:7px;width:7px;border-style: none;"><br></label></span><select name="552868" id="552868" tabindex="35" class="UserInput" grouprequired="true" style="width:515px;">
<option value="-1">(select one)</option>
<option value="2540286" title="">Yes</option>
<option value="2540287" title="">No</option>
<option value="2540288" title="">No</option>
<option value="2540289" title="">Don't Know</option>
<option value="2540290" title="">Don't Want to Say</option>
</select><span id="SpacerAfterDropDownList552868"><br></span><span id="GroupName552869" class="question-name" groupname="Do you have serious difficulty walking or climbing stairs?"><label for="cphBody_552869"><br>Do you have serious
difficulty walking or climbing stairs?<img title="Required" onmouseover="this.style.cursor='pointer';" src="../../images/icon_asterisk.png" alt="Required" style="height:7px;width:7px;border-style: none;"><br></label></span><select
name="552869" id="552869" tabindex="35" class="UserInput" grouprequired="true" style="width:515px;">
<option value="-1">(select one)</option>
<option value="2540291" title="">Yes</option>
<option value="2540292" title="">No</option>
<option value="2540293" title="">No</option>
<option value="2540294" title="">Don't Know</option>
<option value="2540295" title="">Don't Want to Say</option>
</select><span id="SpacerAfterDropDownList552869"><br></span><span id="GroupName552870" class="question-name" groupname="Do you have difficulty dressing or bathing?"><label for="cphBody_552870"><br>Do you have difficulty dressing or
bathing?<img title="Required" onmouseover="this.style.cursor='pointer';" src="../../images/icon_asterisk.png" alt="Required" style="height:7px;width:7px;border-style: none;"><br></label></span><select name="552870" id="552870"
tabindex="35" class="UserInput" grouprequired="true" style="width:515px;">
<option value="-1">(select one)</option>
<option value="2540296" title="">Yes</option>
<option value="2540297" title="">No</option>
<option value="2540298" title="">No</option>
<option value="2540299" title="">Don't Know</option>
<option value="2540300" title="">Don't Want to Say</option>
</select><span id="SpacerAfterDropDownList552870"><br></span><span id="GroupName552871" class="question-name"
groupname="Because of a physical, mental, or emotional condition, do you have serious difficulty concentrating, remembering or making decisions?"><label for="cphBody_552871"><br>Because of a physical, mental, or emotional condition,
do you have serious difficulty concentrating, remembering or making decisions?<img title="Required" onmouseover="this.style.cursor='pointer';" src="../../images/icon_asterisk.png" alt="Required"
style="height:7px;width:7px;border-style: none;"><br></label></span><select name="552871" id="552871" tabindex="35" class="UserInput" grouprequired="true" style="width:515px;">
<option value="-1">(select one)</option>
<option value="2540301" title="">Yes</option>
<option value="2540302" title="">No</option>
<option value="2540303" title="">No</option>
<option value="2540304" title="">Don't Know</option>
<option value="2540305" title="">Don't Want to Say</option>
</select><span id="SpacerAfterDropDownList552871"><br></span><span id="GroupName552872" class="question-name"
groupname="Because of a physical, mental or emotional condition, do you have difficulty doing errands alone such as visiting a doctor’s office or shopping?"><label for="cphBody_552872"><br>Because of a physical, mental or emotional
condition, do you have difficulty doing errands alone such as visiting a doctor’s office or shopping?<img title="Required" onmouseover="this.style.cursor='pointer';" src="../../images/icon_asterisk.png" alt="Required"
style="height:7px;width:7px;border-style: none;"><br></label></span><select name="552872" id="552872" tabindex="35" class="UserInput" grouprequired="true" style="width:515px;">
<option value="-1">(select one)</option>
<option value="2540306" title="">Yes</option>
<option value="2540307" title="">No</option>
<option value="2540308" title="">No</option>
<option value="2540309" title="">Don't Know</option>
<option value="2540310" title="">Don't Want to Say</option>
</select><span id="SpacerAfterDropDownList552872"><br></span><span id="GroupName552873" class="question-name" groupname="Do you have serious difficulty learning how to do things most people your age can learn?"><label
for="cphBody_552873"><br>Do you have serious difficulty learning how to do things most people your age can learn?<img title="Required" onmouseover="this.style.cursor='pointer';" src="../../images/icon_asterisk.png" alt="Required"
style="height:7px;width:7px;border-style: none;"><br></label></span><select name="552873" id="552873" tabindex="35" class="UserInput" grouprequired="true" style="width:515px;">
<option value="-1">(select one)</option>
<option value="2540312" title="">Yes</option>
<option value="2540313" title="">No</option>
<option value="2540314" title="">No</option>
<option value="2540315" title="">Don't Know</option>
<option value="2540316" title="">Don't Want to Say</option>
<option value="2540317" title="">Don't Know What this Question is Asking</option>
</select><span id="SpacerAfterDropDownList552873"><br></span><span id="GroupName552874" class="question-name"
groupname="Do you have serious difficulty with the following: mood, intense feelings, controlling your behavior, or experiencing delusions or hallucinations?"><label for="cphBody_552874"><br>Do you have serious difficulty with the
following: mood, intense feelings, controlling your behavior, or experiencing delusions or hallucinations?<img title="Required" onmouseover="this.style.cursor='pointer';" src="../../images/icon_asterisk.png" alt="Required"
style="height:7px;width:7px;border-style: none;"><br></label></span><select name="552874" id="552874" tabindex="35" class="UserInput" grouprequired="true" style="width:515px;">
<option value="-1">(select one)</option>
<option value="2540318" title="">Yes</option>
<option value="2540319" title="">No</option>
<option value="2540320" title="">No</option>
<option value="2540321" title="">Don't Know</option>
<option value="2540322" title="">Don't Want to Say</option>
<option value="2540323" title="">Don't Know What this Question is Asking</option>
</select><span id="SpacerAfterDropDownList552874"><br></span><span id="GroupName552867" class="question-name"
groupname="Using your usual (customary) language, do you have serious difficulty communicating, (for example understanding or being understood by others)?"><label for="cphBody_552867"><br>Using your usual (customary) language, do
you have serious difficulty communicating, (for example understanding or being understood by others)?<img title="Required" onmouseover="this.style.cursor='pointer';" src="../../images/icon_asterisk.png" alt="Required"
style="height:7px;width:7px;border-style: none;"><br></label></span><select name="552867" id="552867" tabindex="35" class="UserInput" grouprequired="true" style="width:515px;">
<option value="-1">(select one)</option>
<option value="2540281" title="">Yes</option>
<option value="2540282" title="">No</option>
<option value="2540283" title="">No</option>
<option value="2540284" title="">Don't Know</option>
<option value="2540285" title="">Don't Want to Say</option>
<option value="2540311">Don't Know What this Question is Asking</option>
</select><span id="SpacerAfterDropDownList552867"><br></span><span id="GroupName552875" class="question-name"><br>
<div>
<strong>Nearly Done!</strong>
</div>
<div>
<br> These final questions ask about the care you received from 988. You are free to choose "Don't
</div>
<div> Know" or "Don't Want to Answer."</div>
<div> </div>
<br>
</span><span id="GroupName552877" class="question-name" groupname="During your MOST RECENT contact, did the person who responded to you listen carefully to you?"><label for="cphBody_552877"><br>During your MOST RECENT contact, did the
person who responded to you listen carefully to you?<img title="Required" onmouseover="this.style.cursor='pointer';" src="../../images/icon_asterisk.png" alt="Required"
style="height:7px;width:7px;border-style: none;"><br></label></span><select name="552877" id="552877" tabindex="35" class="UserInput" grouprequired="true" style="width:515px;">
<option value="-1">(select one)</option>
<option value="2540328" title="">YES, Definitely</option>
<option value="2540329" title="">YES, Somewhat</option>
<option value="2540330" title="">NO</option>
<option value="2540331" title="">Don't Want to Answer</option>
</select><span id="SpacerAfterDropDownList552877"><br></span><span id="GroupName552878" class="question-name" groupname="Did the person who responded to you respect what you had to say?"><label for="cphBody_552878"><br>Did the person
who responded to you respect what you had to say?<img title="Required" onmouseover="this.style.cursor='pointer';" src="../../images/icon_asterisk.png" alt="Required"
style="height:7px;width:7px;border-style: none;"><br></label></span><select name="552878" id="552878" tabindex="35" class="UserInput" grouprequired="true" style="width:515px;">
<option value="-1">(select one)</option>
<option value="2540332" title="">YES, Definitely</option>
<option value="2540333" title="">YES, Somewhat</option>
<option value="2540334" title="">NO</option>
<option value="2540335" title="">Don't Want to Answer</option>
</select><span id="SpacerAfterDropDownList552878"><br></span><span id="GroupName552879" class="question-name" groupname="Did the person who responded to you spend enough time with you?"><label for="cphBody_552879"><br>Did the person
who responded to you spend enough time with you?<img title="Required" onmouseover="this.style.cursor='pointer';" src="../../images/icon_asterisk.png" alt="Required"
style="height:7px;width:7px;border-style: none;"><br></label></span><select name="552879" id="552879" tabindex="35" class="UserInput" grouprequired="true" style="width:515px;">
<option value="-1">(select one)</option>
<option value="2540336" title="">YES, Definitely</option>
<option value="2540337" title="">YES, Somewhat</option>
<option value="2540338" title="">NO</option>
<option value="2540339" title="">Don't Want to Answer</option>
</select><span id="SpacerAfterDropDownList552879"><br></span><span id="GroupName552876" class="question-name" groupname="Did the person who responded to you support and help you?"><label for="cphBody_552876"><br>Did the person who
responded to you support and help you?<img title="Required" onmouseover="this.style.cursor='pointer';" src="../../images/icon_asterisk.png" alt="Required" style="height:7px;width:7px;border-style: none;"><br></label></span><select
name="552876" id="552876" tabindex="35" class="UserInput" grouprequired="true" style="width:515px;">
<option value="-1">(select one)</option>
<option value="2540324">YES, Definitely</option>
<option value="2540325">YES, Somewhat</option>
<option value="2540326">NO</option>
<option value="2540327">Don't Want to Answer</option>
</select><span id="SpacerAfterDropDownList552876"><br></span><span id="GroupName574515" class="question-name" groupname="How did you feel after contacting us?"><label for="cphBody_574515"><br>How did you feel after contacting
us?<br></label></span><input name="574515" type="text" id="574515" tabindex="35" class="UserInput" grouprequired="false" style="width:70px;"><span id="SpacerAfterTextBox574515"><br></span><span id="GroupName552880"
class="question-name" groupname="Would you say that your language, race, religion, ethnic or cultural background makes any difference in the kind of counseling or treatment you seek?"><label for="cphBody_552880"><br>Would you say
that your language, race, religion, ethnic or cultural background makes any difference in the kind of counseling or treatment you seek?<br></label></span><select name="552880" id="552880" tabindex="35" class="UserInput"
grouprequired="false" style="width:515px;">
<option value="-1">(not applicable)</option>
<option value="2540340">Yes</option>
<option value="2540341">No</option>
</select><span id="SpacerAfterDropDownList552880"><br></span>
</strong></div>
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IF YOU SUBMITTED THIS SURVEY ALREADY, PLEASE DO NOT COMPLETE IT AGAIN. ▪YOU CAN ANSWER THESE QUESTIONS ANY WAY YOU WANT. ▪YOU CAN CHOOSE NOT TO ANSWER A QUESTION. ▪YOUR ANSWERS ARE NOT CONNECTED TO YOUR CALL RECORD. ▪YOUR ANSWERS WILL NOT NEGATIVELY IMPACT YOUR SERVICES OR ABILITY TO RECEIVE BENEFITS IN ANY WAY. NORTHWEST HUMAN SERVICES SHARES DE-IDENTIFIED DATA FROM THIS SURVEY WITH OUR FUNDERS, INCLUDING THE OREGON HEALTH AUTHORITY. THANK YOU FOR YOUR TIME! Race, Ethnicity, Language and Disability We would like to know your race, ethnicity, language and disability background so that we can find and address unfair health and service differences. You are free to choose "Don't Know/Unknown" or "Don't Want to Say." In your own words, how would you identify your race, ethnicity, tribal affiliation, country of origin, or ancestry? Which of the following describes your racial or ethnic identity? * American Indian, Alaska Native or Indigenous Peoples of Canada, Mexico, Central or South America * Hispanic and Latino/a/x * Native Hawaiian and Pacific Islander * Black and African American * Asian * Middle Eastern/ North African * White * Other * Don't Know * Don't Want to Say Now we ask about specific identities. If you checked more than one category above, is there one you think of as your primary racial or ethnic identity? (select one) N/A -- Not applicable. I did not check Yes. There is ONE racial or ethnic identity that I think of as PRIMARY. No. I identify as Biracial or Multiracial I do not have just one primary racial or ethnic identity Don't Know Don't Want to Answer What languages do you use at home? We are hoping to offer services in additional languages. What is the ONE language you most prefer to use when communicating with us BY TEXT? We are hoping to offer services in additional languages. Please write-in the ONE language you most prefer to use when communicating with us BY PHONE? What is your gender? (not applicable) Woman/Girl Man/Boy Agender/ No gender Non-binary Questioning Don't know I don't know what this question is asking I don't want to answer Are you transgender? (not applicable) Yes No I don't know what this question is asking I don't want to answer Don't know How do you describe your sexual orientation or sexual identity? (not applicable) Same-sex loving Same-gender loving Lesbian Gay Bisexual Straight (attracted mainly to or only to other gender(s)) Pansexual Asexual Queer Questioning Don't know I don't know what this question is asking Enter your age What is your zip code? Have you ever served on active duty in ANY branch of the military (Army, Navy, Air Force, Marine Corps, Coast Guard, National Guard or Reserves)? (not applicable) Yes, I am currently on active duty Yes, I have served in the past No, Never on active duty except for basic/military Training No, Never on active duty In the past year, have you or any family members you live with been unable to get any of the following when it was really needed? * Food * Utilities * Medicine or any health care need (Medical, Dental, Mental Health, Vision) * Phone * Reliable home internet * School books or supplies * Clothing * Child Care * Safe and stable housing * Transportation What kinds of health insurance or health care coverage do you have? (select one) Children’s Health Insurance Program (CHIP) Don’t Know Indian Health Service Medicaid Medigap Military related health care: TRICARE (CHAMPUS)/VA health care/CHAMPVA Medicare No coverage of any type Other government program Private health insurance (Employer or Individual Plan) Refused State-sponsored health plan (Oregon Health Plan) The next questions ask about functional limitations. There are no 'right' answers Are you deaf or do you have serious difficulty hearing? (select one) Yes No No Don't Know Don't Want to Say Are you blind or do you have serious difficulty seeing, even when wearing glasses? (select one) Yes No No Don't Know Don't Want to Say Do you have serious difficulty walking or climbing stairs? (select one) Yes No No Don't Know Don't Want to Say Do you have difficulty dressing or bathing? (select one) Yes No No Don't Know Don't Want to Say Because of a physical, mental, or emotional condition, do you have serious difficulty concentrating, remembering or making decisions? (select one) Yes No No Don't Know Don't Want to Say Because of a physical, mental or emotional condition, do you have difficulty doing errands alone such as visiting a doctor’s office or shopping? (select one) Yes No No Don't Know Don't Want to Say Do you have serious difficulty learning how to do things most people your age can learn? (select one) Yes No No Don't Know Don't Want to Say Don't Know What this Question is Asking Do you have serious difficulty with the following: mood, intense feelings, controlling your behavior, or experiencing delusions or hallucinations? (select one) Yes No No Don't Know Don't Want to Say Don't Know What this Question is Asking Using your usual (customary) language, do you have serious difficulty communicating, (for example understanding or being understood by others)? (select one) Yes No No Don't Know Don't Want to Say Don't Know What this Question is Asking Nearly Done! These final questions ask about the care you received from 988. You are free to choose "Don't Know" or "Don't Want to Answer." During your MOST RECENT contact, did the person who responded to you listen carefully to you? (select one) YES, Definitely YES, Somewhat NO Don't Want to Answer Did the person who responded to you respect what you had to say? (select one) YES, Definitely YES, Somewhat NO Don't Want to Answer Did the person who responded to you spend enough time with you? (select one) YES, Definitely YES, Somewhat NO Don't Want to Answer Did the person who responded to you support and help you? (select one) YES, Definitely YES, Somewhat NO Don't Want to Answer How did you feel after contacting us? Would you say that your language, race, religion, ethnic or cultural background makes any difference in the kind of counseling or treatment you seek? (not applicable) Yes No Please Wait... To access this web site, Javascript must be enabled on your web browser. For instructions on how to enable Javascript on your browser, please visit http://enable-javascript.com/. Submission Review Close Would you like to submit the following answers? Submit AnswersCancel Inactivity Warning Close Due to inactivity, your session may time out and end. If you'd like to continue, click CONTINUE, otherwise click EXIT. ContinueExit