Chamberlain University College of Nursing NR443/435/436 Community Health Nursing
NR443/435/436: Community Windshield Survey Form
Directions: Please refer to the Community Windshield Survey Guidelines and grading rubric in your NR443/435/436 course for specific instructions in order to complete the information below. You are required to use this form for your submission.
Drive through the community where you live or work several times. Document your observations in order to complete the tables below.
Name: Date:
1. Community Description
| Name of city or town and state: |
| Name of the street or road where you live or work in this community: |
| Nature of this community (rural, suburban, urban): |
| Briefly describe your community: |
2. Community Vitality
| Question | Many | Some | Few or None |
| Did the people you observed during your drive though appear healthy? | ☐ | ☐ | ☐ |
| Did you see people with obvious physical disabilities, such as those using walkers or wheelchairs? | ☐ | ☐ | ☐ |
| Did you see those with apparent mental or emotional disabilities? | ☐ | ☐ | ☐ |
| Did you observe people smoking tobacco products? | ☐ | ☐ | ☐ |
| Did you observe people who appear to be under the influence of drugs or alcohol? | ☐ | ☐ | ☐ |
| Did you see pregnant women? | ☐ | ☐ | ☐ |
| Did you see pregnant adolescents? | ☐ | ☐ | ☐ |
| Did you see young women or men with strollers or young children? | ☐ | ☐ | ☐ |
| Answer the following questions using complete sentences. | |||
| What was the approximate age range of the people you saw: Youngest ________ Oldest________ | |||
| Describe the general appearance of those you observed (thin, obese, fit, undernourished, etc.): | |||
| Describe the dress of those you observed (unkempt, torn, appropriate, well-dressed, etc.): | |||
| Briefly describe what the people you observed were doing (driving, exercising, socializing, etc.): |
3. Indicators of Social and Economic Conditions
| Question | Many | Some | Few or none |
| Did you observe housing that was run down or dilapidated? | ☐ | ☐ | ☐ |
| Were any areas undergoing renewal? | ☐ | ☐ | ☐ |
| Was public housing observed? | ☐ | ☐ | ☐ |
| Was there public transit? | ☐ | ☐ | ☐ |
| Were there bus stops? | ☐ | ☐ | ☐ |
| Was transportation to health care resources observed? | ☐ | ☐ | ☐ |
| Were there job opportunities nearby, such as factories, small businesses, or military installations? | ☐ | ☐ | ☐ |
| Were there unemployed people visible, such as homeless people? | ☐ | ☐ | ☐ |
| Did you see people congregating in groups on the street? | ☐ | ☐ | ☐ |
| Did you note any seasonal workers, such as migrant or day laborers? | ☐ | ☐ | ☐ |
| Did you observe any children or adolescents out of school during the typical school hours? | ☐ | ☐ | ☐ |
| Did you observe any political signs? | ☐ | ☐ | ☐ |
| Do you see any evidence of health education on billboards, advertisements, or signs? | ☐ | ☐ | ☐ |
| Answer the following questions using complete sentences. | |||
| What kinds of housing did you observe (detached homes, apartments, etc.)? | |||
| Describe the general condition of the housing you observed: | |||
| Describe the forms of transportation you saw people using: | |||
| Describe the main types of work you observed that were available to residents? | |||
| What kinds of schools and day care centers were observed? |
4. Health Resources
Complete the table below with approximate numbers of health resources you observed when you drove through your community.
| Health Resource | Number observed | Health Resources | Number observed |
| Hospitals | Urgent Care Clinics | ||
| Community Clinics | Skilled nursing facilities | ||
| Family Planning Clinics | Mental health or counselling clinics | ||
| Generalist Doctors | Homeless or Abuse Shelters | ||
| Dentist offices | Public Health Department Office | ||
| Pharmacies | Substance Abuse Treatment Center | ||
| Answer the following questions using complete sentences. | |||
| If some of the above health resources were not observed, approximately how far away would a person need to travel to find these resources? | |||
| Do these resources seem sufficient to address the kinds of problems that exist in this community? |
5. Environmental Conditions Related to Health
| Question | Many | Some | Few or none |
| Did you see evidence of anything that might make you suspicious of ground, water, or air pollutants? | ☐ | ☐ | ☐ |
| Did you observe poor road conditions with potholes, or poor drainage? | ☐ | ☐ | ☐ |
| Are there adequate traffic lights, signs, sidewalks, and curbs? | ☐ | ☐ | ☐ |
| Are railroad crossings fitted with warnings and barriers? Are streets and parking lots well lit? | ☐ | ☐ | ☐ |
| Was there handicapped access to buildings, sidewalks, and streets? | ☐ | ☐ | ☐ |
| Did you observe recreational facilities, playgrounds, and/or facilities like the YMCA? | ☐ | ☐ | ☐ |
| Were recreational facilities being used? | ☐ | ☐ | ☐ |
| Were children playing in the streets, alleys, yards, or parks? | ☐ | ☐ | ☐ |
| Did you see any restaurants? | ☐ | ☐ | ☐ |
| Was there any evidence of nuisances such as ants, flies, mosquitoes, or rodents, or stray animals observed? | ☐ | ☐ | ☐ |
6. Social Functioning
| Question | Many | Some | Few or none |
| Did you observe any group efforts in the neighborhood to improve the living conditions or the neighborhood? | ☐ | ☐ | ☐ |
| How many churches, synagogues, and other places of worship did you observe? | ☐ | ☐ | ☐ |
| Answer the following questions using complete sentences. | |||
| Describe the general types of churches, synagogues, and other places of worship you observed. | |||
| Describe interactions observed among family or friends during survey. Is more than one generation present? | |||
| Were children out playing and if so were they appropriately supervised? | |||
| Were there any identifiable subgroups either of people socially or geographically? | |||
| Describe evidence of community cohesiveness that you observed (such as signs of a neighborhood watch or other social events or clubs). | |||
| Describe any observations that made you suspicious of social problems, such as graffiti, evidence of gang activity, juvenile delinquency, or drug or alcohol abuse? |
7. Attitudes toward Health and Healthcare.
| Question | Many | Some | Few or none |
| Did you observe any evidence of folk medicine practice, such as alternative medicine practices, botanicals, or herbal medicine shops? | ☐ | ☐ | ☐ |
| Did you observe that health resources were underutilized? | ☐ | ☐ | ☐ |
| Was there evidence of preventive or wellness care? | ☐ | ☐ | ☐ |
| Did you observe any efforts to improve the neighborhood’s health such as advertisements for health-related events, health fares, clinics, or lectures? | ☐ | ☐ | ☐ |
8. Aggregates or Vulnerable Populations Observed.
| Which aggregates or vulnerable groups did you observe during your survey? (Click all that you saw.) | |
| ☐ Infants and Children | ☐ Pregnant women or adolescents |
| ☐ Adolescents | ☐ Recent immigrants |
| ☐ Seniors | ☐ Migrant Workers |
| ☐ Those living in poverty | ☐ Those affected by mental illness |
| ☐ Those who are homeless | ☐ Disadvantaged ethnic groups |
| Answer the following question using complete sentences. | |
| Thoroughly describe what you observed about one aggregate or vulnerable group that you identified above (i.e. gender, behavior, age, appearance, etc.): |
9. Health Problems and Health Behaviors Observed
| Answer the following questions using complete sentences. |
| Describe positive health behaviors that you observed during your survey: |
| Describe unhealthy behaviors that you observed during your survey: |
| Describe health problems you observed during your survey or potential health problems that you would anticipate based on your observations: |
10. Health Problem and Healthy People (HP) Objective
| Identify one Priority Community Health Problem Diagnosis (other than the problem listed in the example in the Guidelines): | |
| HP Objective Number (other than FP-8.1) | |
| HP Objective for the number you listed. |
11. Summary of Learning
| Reflect on the experience of completing this windshield survey and summarize what you learned that might impact your current or future nursing practice. This could be something unexpected or surprising that you did not notice before. |
12. Optional Community Picture
| Insert one or two pictures that you took during your survey that demonstrates some of your findings. Avoid close up pictures of individuals. You may need to resize the photo so that it fits on the page (search the Web for tips). If your document has difficulty loading in Canvas, remove the picture(s) and resave the document and then try loading it again without the picture(s). |
| Picture 1 |
| Picture 2 |
References
Nies, M. A., & McEwen, M. (2019). Community/Public health nursing: Promoting the health of populations (7th ed.). St. Louis, MO: Saunders/Elsevier.
U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion: Healthy People 2020. (2018). Objectives. Retrieved from https://www.healthypeople.gov/2020/topics-objectives/
| NR443_435_436 Windshield Survey Form 11/2018 MM_v.2 | 1 |
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