Questionnaire Form:

1) Your Primary source of Health Care for the past 12 months?

A) Hattiesburg Health Plan

B) OPD

C) Private Physician

D) Others

2) In General how do you rate your Health?

Excellent Very Good Good Fair Poor
3) Are you suffering with any long lasting diseases (Chronic
Diseases?)
o Yes
o No
4) What type of treatment you are receiving outside your health
plan in the past 12 months? Click all which applies to you
Physical
Mental
Dental
Prescription
Emergency
Not Eligible
5) What is your reason for reaching other physicians other than your
plan in the last 12 months?
A) Cost Effective

B) Mode of Treatment C) Others ____________

6) Please state your opinion on Hattiesburg Health plan on the scale

below Click all that apply
Strongly agree
Strongly Disagree
Useful
Caring
Satisfact

Agree

Neither

Disagree

ory
Reachabl
e

7) What is your current status of your Employment?

A) Full time

B) Part time

C) Not Working

8) What is your household annual Income ?

___ Below 10000
100000$ and more

$ ___ 10000 40000$

___ 40000 -75000 $

___

9) How many Children do you have?

A One

B) Two

C) three and More

4)

None
10) Race
13) Residence
Caucasian
North Side
African American
West Side

11) Age
Below 20

21 -40

Asian
side

41-60

Hawaiian
Side

above 60

Others
14)

Your Gender
A) Male

12) Education

B) Female

below 8th grade

High School Graduate

Graduate

above Graduate

East

West