Activist Tool Kit

Survey

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

[] Medicare

[] Other:________________

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

    1. Do you believe it is the role of our government to make sure that everyone has health care? [] YES [] NO [] NOT SURE
    2. Would 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.

    Name: ___________________________________________________________

    Phone: ( ) -

    Cell phone: ( ) -

    Address:______________________________

    City: ______________________________

    Email:________________________________________________________________

    My story and contact information may be used by HCAO, its member organizations,
    and HCAO-Education Fund   Yes [ ] No [ ]

    Signature_______________________________