Identifying Our Needs: The Problem
1. Have you ever had problems getting the health care you need?  YES  NO
a) What made it difficult to get care? ___________________________________________________
b) Do you have medical insurance?  YES  NO
If YES, what type?
 Through employer  Medicaid/OHP
2. Have you ever been unable to get the health care you need because of costs?
 YES  NO
a) If YES, what type of care? [ ] Regular check-ups [ ] Surgery [ ] Prescription Drugs
 Mental Health Care  Dental Care  Vision care/glasses  Other:___________________
b) What costs have been difficult for you?
 Premiums  Deductible  Co-pays  Paying bills out-of-pocket  Other: _______________
3. Have you, or someone in your family, ever experienced any of the following?
a) Stayed in a job to keep health insurance  YES  NO
If YES, please describe:____________________________________________________
b) Experienced discrimination when trying to get health care because of your race, immigration status, gender, sexual orientation, age, or disability?  YES  NO
If YES, please describe: ____________________________________________________________
c) Developed more serious health problems because high costs/limited insurance delayed getting the treatment you needed?  YES  NO
If YES, please describe:________________________________________________
d) Had problems with medical debts?  YES  NO
If YES, please describe:_______________________________________________
Claiming Our Rights
4. Do you think we should make sure everyone in our state can get the health care they need?  YES  NO
5. Do you believe that health care is a human right?  YES  NO
- Do you believe it is the role of our government to make sure that everyone has health care?  YES  NO  NOT SURE
you say that the human right to health care is protected in Oregon?
 YES  NO  NOT SURE
6. Do you feel you have a say in decisions about our health care system?  YES  NO
Responsibilities of Government: The Solution
7. What do you think of the idea of a universal health care system, which would be publicly funded from our taxes, rather than by paying premiums and deductibles to insurance companies?  LIKE IT  DON’T LIKE  NOT SURE
8. If you could change anything about our health care system, what would it be?
About you (this will help us analyze the results of this survey)
9. Summarize your health care story. _______________________________________________________________
10. Are you willing to share your name and story with HCAO, its member organizations, and HCAO-EF for use in public media and direct conversations with legislators Yes [ ] No [ ]
11. What is your ZIP CODE? ________________12. What is your age? ___________
13. What is your gender? [ ] Female [ ] Male [ ] Transgender
14. What is your race or ethnicity?
[ ] African American
[ ] Asian/Pacific Islander
[ ] Latino/Hispanic
[ ] Middle Eastern
[ ] Native/Indigenous
[ ] White/ European American
[ ] Other: ________________
Thank you for completing this survey!
Do you want more information about our Health Care is a Human Right campaign?
You do not have to give your personal information to complete this survey. You can choose to remain anonymous. However, if you would like more information, please complete the section below:
[ ] YES, I want to get involved! [ ] YES, I would like more information.
Phone: ( ) -
Cell phone: ( ) -
story and contact information may be used by HCAO, its member
and HCAO-Education Fund Yes [ ] No [ ]