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<br /> <br /> <br /> <br /> <br />2015 Orange County Community Health Opinion Survey <br /> <br />Date COMMENTS <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> Description ADMIN ONLY <br /> <br />Follow Up? <br /> <br />Phone Number: <br />____________________________ <br /> <br />Address: <br />____________________________ <br /> <br />____________________________ <br /> <br />Email: <br />____________________________ <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br />€ No One Home <br />€ Language Barrier <br /> Spanish <br /> Other: ____________________ <br />(Call back to complete? Provide phone <br />number) <br /> <br />€ Ended Before Survey Completed <br />(Call back to complete? Provide phone <br />number) <br /> <br />€ No one in home eligible <br /> Under 18 years of age <br /> Non-resident of Orange County <br /> <br />€ Household Refusal <br />€ Unoccupied/Vacant/Demolished House <br />€ Selected Address Not a Household <br />€ Survey Completed <br /> Yes <br /> No <br />