ORANGE COUNTY COMMUNITY HEALTH ASSESSMENT 2010 2013

ORANGE COUNTY COMMUNITY HEALTH ASSESSMENT 2010 2013 Edward A. Diana County Executive Jean M. Hudson, M.D., M.P.H. Commissioner of Health

ORANGE COUNTY COMMUNITY HEALTH ASSESSMENT 2010-2013 TABLE OF CONTENTS Acknowledgements Executive Summary and Key Findings Exhibit Listing Guide to Statistical Terms Community Health Assessment (CHA) Index Section 1 Populations at Risk Page A. Demographic and Health Status Information 1-23 1. The Population of Orange County 1-5 a. Population Growth Rates and Density b. Population Demographics c. Employment and Housing Characteristics d. Projected Demographic Changes e. Regional Perspective 2. Causes of Mortality in Orange County 5-7 a. Overall Mortality b. Mortality Rates of Demographic Subpopulations c. Leading Causes of Death 3. Health Status of County Residents 7-15 a. Family Health Child and Adolescent Health Maternal and Infant Health, Reproductive Health & Family Planning Intentional and Unintentional Injuries b. Disease Control 15-23 Sexually Transmitted Diseases HIV/AIDS Tuberculosis Other Communicable Diseases Vaccine Preventable Diseases Chronic Diseases B. Access to Care 24-28 1. Availability and Utilization of Health Care Services 24-26 2. Barriers to Health Care Access 26-28 a. Financial b. Structural c. Personal C. Behavioral Risk Factors 1. Core Behavioral Risk Factors 30-37 2. Optional Behavioral Risk Factors 37-39 3. Selected Youth Behavioral Risk Factors 39-40 D. The Local Health Care Environment 1. History 41 2. Physical and Social Factors 41-42 3. Economic Factors 43-44

E. Section One Exhibits 46-263 Section 2 Local Health Unit Capacity Profile Page A. Organizational Structure and Program Description 1-9 B. Current Trends and Workload 10-17 C. New Initiatives and Significant Accomplishments 18-20 D. Staff Qualifications and Skill Levels 21-22 E. Expertise and Technical Capacity for Community Health Assessments 23 Section 3 Problems and Issues in the Community Page A. Profile of Community Resources 1-31 B. Profile of Unmet Need for Health Services 1-3 Section 4 Local Health Priorities Page A. Priority Local Needs 1-16 Priority Health Needs Accomplishments Related to Priority Areas Section 5 Opportunities for Action Page A. Opportunities and Potential Action Steps 1-4 Section 6 Community Report Card Page Introduction 1 County Health Indicator Profiles 2-3 Orange County Indicators for Tracking Public Health Priority Areas 4-7

ORANGE COUNTY COMMUNITY HEALTH ASSESSMENT 2010-2013 ACKNOWLEDGMENTS Many thanks to all who worked to bring this document together: Prevention Agenda Workgroup (see listing) Orange County Department of Health Division Directors: Chris Dunleavy, Deputy Commissioner of Health Robert Deitrich, Director, Community Health Outreach Marilyn Ejercito, R.N., M.S., Director, Public Health Nursing Christopher Ericson, M.P.A., Director, Public Health Response Matthias Schleifer, P.E., Assistant Commissioner, Environmental Health Anne Vradenburgh, Director, Fiscal Sheila Warren, R.N., M.Ed., Director, Intervention Services Charles A. Catanese, M.D., Chief Medical Examiner Robert Hastings, Health IT Consultant Colleen Larsen, R.N., M.P.A., OCDOH Nurse Epidemiologist Jacqueline Lawler, M.P.H., OCDOH Epidemiology Fellow Chris Saccone, Executive Secretary/Administrative Assistant Ed Waltz, Ph.D., Director, and Susan Wymer, B.S.N, R.N., Graduate Research Assistant, Prevention Research Center, SUNY Albany School of Public Health Mary Bevan, M.P.H., Project Director (Consultant) Jean M. Hudson, M.D., M.P.H. Commissioner of Health Orange County Community Health Assessment 2010-2013

ORANGE COUNTY COMMUNITY HEALTH ASSESSMENT 2010-2013 EXECUTIVE SUMMARY The 2010-2013 Community Health Assessment (CHA) represents the ongoing efforts of representatives from community-based health, social service, mental health, and education agencies, health care providers, Advisory Board of Health and Health Department representatives to identify health needs and to collectively determine strategies to improve the health of County residents. Submission of the CHA is a requirement of the Municipal Public Health Services Plan. A complete assessment is conducted every four years. New York State regulations designate the county health department as the lead agency in the preparation and submission of the CHA. As stated in the 2010-2013 NYSDOH CHA Guidance document, Community health assessment is a core function of public health agencies and a fundamental tool of public health practice. Its aim is to describe the health of the community, by presenting information on health status, community health needs, resources, and epidemiologic and other studies of current local health problems. It seeks to identify target populations that may be at increased risk of poor health outcomes and to gain a better understanding of their needs, as well as assess the larger community environment and how it relates to the health of individuals. It also identifies those areas where better information is needed, especially information on health disparities among different subpopulations, quality of health care, and the occurrence and severity of disabilities in the population. The CHA is the basis for all local public health planning, giving the local health unit the opportunity to identify and interact with key community leaders, organizations and interested residents about health priorities and concerns. New York s Prevention Agenda toward the Healthiest State initiative was launched in April 2008, to promote collaborative community health planning focused in locally-selected health priority areas. The Prevention Agenda designates local health departments and hospitals as the lead partners in this process. Involving key community stakeholders, 2-3 priority areas are selected based on consideration of demographic and health status data, health service delivery data, local and regional surveys and studies. Opportunities for action are identified to focus improvement efforts and maximize outcomes through coordination and collaboration. National and state benchmarks, such as Healthy People 2010 and Prevention Agenda 2013 targets are used to monitor and evaluate progress. Several strategies were used to encourage community input in establishing community health priorities. The primary strategy is ongoing community collaboration. In addition, two versions of a local health needs survey were developed to solicit input on local health needs from health providers, community agencies, and residents. More than 160 provider/community agency and 760 resident surveys were completed. Representatives from community agencies throughout the county also participated in Health Town Meetings held in 4 distinct geographic areas of the county. These meetings were hosted by the primary hospital/medical center in each region and the discussions were facilitated by representatives from each Community Health Center serving county residents. The surveys and Health Town meetings attempted to capture as broad participation as possible and reflect the priority health issues in the communities in each area. Despite slight differences in geographic emphasis, the primary concerns raised were highly consistent. This information, as well as analysis of the demographic, mortality, morbidity, and behavioral risk indicators discussed in Section I Populations at Risk informed the selection of local health priorities aligned with the NYS Prevention Agenda. A Prevention Agenda Workgroup was convened to finalize the determination of unmet health and service needs, local health priorities, and opportunities for action. Workgroup representatives have extensive experience in public health and health services delivery, including service to high risk populations throughout the county. Working with a public health consultant, researchers from the SUNY Albany School of Public Health, the OCDOH epidemiologist, and Division Directors formed our CHA development team. The determination of local health priorities was guided by the 10 priority areas for public health action specified in The Prevention Agenda for the Healthiest State. Orange County Community Health Assessment 2010-2013 1

The majority of residents in Orange County enjoy favorable health. Preliminary results from the most recent NYSDOH Expanded Behavioral Risk Surveillance Survey found that 86% of Orange County adults ages 18 and over surveyed reported their health status to be good to excellent. Access to quality primary health care services is essential to maintain and improve health in the community. Access to primary care promotes a consistent source of care to receive preventive health education and health screenings, early detection and treatment of disease, and timely referrals for specialty care and other needed services. Ongoing contact with a primary health care provider is essential to prevent complications and improve health outcomes. Orange County is relatively well supplied with primary care providers, however all residents do not have adequate access. The leading health issues in Orange County, as in the state and the nation, result from a number of factors, many of which can be controlled or modified. Harmful personal behaviors such as smoking, overeating, poor nutrition, lack of physical activity, substance abuse, and unsafe sexual practices have major impacts on individual health. Economic and language/cultural factors present barriers to access and utilization of medical care and preventive health services. Income, unemployment, educational attainment, inadequate housing, and lack of transportation are social factors which impact health or limit access to care. Uncontrollable factors, including inherited health conditions or increased susceptibility to disease, also significantly influence health. In spite of the favorable health status enjoyed by most Orange County residents, health disparities persist and are concentrated in the county s uninsured and low income population groups. Lack of health insurance and inadequate insurance coverage are increasing concerns in the current economic recession. Even individuals and families with health insurance can find navigating the health care system difficult especially when faced with personal or family illness. Persons who live in poverty or are uninsured are more likely to have poor health status. Poverty underlies many of the social factors that contribute to poor health. Differences for many health indicators are also apparent by gender, race/ethnicity, age, and geographic area of residence. This information can be used to determine subgroups in the population in need of further assessment, as well as to guide the development of programs and services to meet identified health needs. Recent trends in health indicators for County residents show improvement in overall mortality rates from the leading causes of death most notably heart disease and cancer. Key indicators of maternal and infant health, such as births and pregnancies in teens, infant mortality and low birthweight births, have also improved for county residents overall. There are indications of improvement in personal health habits such as smoking rates and accessing screening services for early detection of certain diseases. However, disparities in health care access and health status in high risk populations persist. The 2010-2013 CHA also indicates areas in need of improvement in county residents such as unintentional injuries, ambulatory care sensitive conditions, Prevention Quality Indicators for chronic diseases, receipt of early prenatal care, prevalence of smoking and obesity, asthma-associated illness, cancer incidence, and disparities in mortality from chronic diseases. Expanded joint planning and coordination of programs and services among health care partners in the community focused in the health priority areas can reduce health disparities and improve the health of all county residents. The intent is for the Community Health Assessment to have significant value for the community, and to be used to advance health-related service planning by a multitude of agencies. We welcome your comments and reactions to this report, and invite you to participate in the assessment process going forward. Jean M. Hudson, M.D., M.P.H. Commissioner of Health Orange County, New York September 2009 Orange County Community Health Assessment 2010-2013 2

ORANGE COUNTY COMMUNITY HEALTH ASSESSMENT 2010-2013 KEY FINDINGS Demographic Trends According to the U.S. Census population estimates published by the New York State Data Center, Orange County is the fastest-growing county in New York State; from April 1, 2000 to July 1, 2007, the county s population increased by an estimated 10.5%. Trends in population growth vary greatly by municipality - communities with estimated population growth rates of twenty percent or more from 2000-2007 include the towns of Minisink and Monroe, and the villages of Kiryas Joel, Maybrook, and Montgomery. Based on 2007 U.S. Census population estimates, the median age in the county has remained relatively constant (34.6 years); the greatest number of residents fall in age range 25-54. The number of residents ages 65-69 is forecasted to more than double from 2000-2020 primarily due to the entry of baby boomers into these age ranges. According to 2007 U.S. Census population estimates, the county s single race composition is: 84.8% White, 10.6% Black/African American, 2.4% Asian with the remaining 2.2% classified as other. Hispanic/Latino, which is not a racial category, represents 15.9% of the county population. Since the 2000 Census, the greatest estimated rate of growth is in the Asian/Pacific Islander population which increased by 75%. The second highest increase was in the Hispanic/Latino population, which grew by 50%. During this time, the Black/African American population is estimated to have increased by 44% and the White population increased the least at 12%. According to the U.S. Census, over nine thousand (9,082) foreign born persons entered Orange County from 1990-2000, up from 6,964 from 1980 to 1990. The majority (45.2%) were born in Latin America, 34.1% were born in Europe, and 16.4% were born in Asian countries. Kids Well-Being Clearinghouse data report that the number of Orange County students K-12 with limited English proficiency increased by 35% from 2000 to 2007, from 9.3% to 12.6%. Recent educational attainment indicators for Orange County youth indicate improvement in educational performance and in the intent to pursue higher education. The percent of high school graduates receiving Regents Diplomas in Orange County s Public Schools increased substantially from 1999-2000 to 2006-2007 (49.9% to 81.6%), in part due to the phase-in of Regent only diplomas statewide. The number of high school graduates intending to enroll in college also increased during this same period, from 81% to 83.7%. Poverty rates vary greatly throughout the county based on municipality. Poverty rates exceeding 25% for families with related children under 18 are found in Orange County s three cities (Middletown, Newburgh, and Port Jervis), as well as in the town of Monroe, largely due to the impact of the village of Kiryas Joel, where the poverty rate is more than 4 times the county average. Levels of poverty in the county also vary depending on race, ethnicity and family composition. Married couple families have the lowest overall poverty rates; the highest rates are seen in single mother families, and this rate exceeds 50% in single mother families with children under the age of five. Housing units within the county increased an estimated 9.2% from 2000 to 2007. The majority of housing units in the county are owner occupied; however this also varies by municipality. Communities with 50% or more of their housing units consisting of pre-1950 construction include Cornwall, Highlands, and the county s three cities of Middletown, Newburgh, and Port Jervis. Among the seven counties in the Hudson Valley Region (HVR), Orange County is the second most populated county, and ranks second in the rate of population growth from 1990-2000 and in the number of Hispanic/Latino residents. Orange County Community Health Assessment 2010-2013 1

Health Status and Risk Indicators Overall Mortality and Leading Causes of Death: Since 1998-2000, there has been a steady decline in the 3-year average age-sex adjusted mortality rate in the county. The 2004-2006 age-sex adjusted mortality rate for county residents was below the Upstate rate. In 2004-2006, the mortality rate for Black/African American residents in the county is highest, followed by that for White residents. Hispanic/Latinos have the lowest overall mortality rate in the county, which may be due in part to underreporting of ethnicity on death certificates. The leading causes of death in the county, as well as in the state and nation, vary by age. In 2005-2007, heart disease and cancer together accounted for over half (53%) of all county resident deaths, and are the leading causes of death in adults ages 45 and over. The leading cause of death in children, adolescents, and young adults is accidents, in adults ages 25-44 the leading causes are cancer followed closely by accidents. Child Health: In general, the health of Orange County children is relatively good; however, there are vulnerable groups within the population who lack consistent access to primary and preventive health care such as children living in low income families without health care insurance. Analysis of the most recent comparative data (2004-2006) shows improvement in hospitalization rates for children ages 0-4 for the following ambulatory care sensitive (ACS) conditions: asthma, pneumonia, and otitis media. Improvements in hospitalization rates for otitis media are dramatic, and in 2004-2006 were below those of the state, upstate, and HVR. Three-year hospitalization rates for Orange County infants and children ages 0-4 remain consistently above those for the HVR for the other ACS conditions. The screening rate for lead poisoning in children under 6 years of age remains in need of improvement. In addition, findings of the 2003 NYSDOH Oral Health Survey were suggestive of a lack of access to or utilization of preventive oral health services in third grade children. Adolescent Health: Adolescents in Orange County generally enjoy favorable health. Health risks in teens most often include risky behaviors related to sexuality, alcohol, tobacco, and drugs, and accidents. Pregnancy and birth rates in teens ages 15-19 have declined in Orange County from 1997-2006. Nonetheless, in 2004-2006, pregnancy and birth rates were the second highest in the HVR; the highest rates in the county are found in minority teens and in the county s 3 cities. Indicators of youth risk behaviors related to drug and alcohol use and for certain sexually-transmitted diseases indicate the need for enhanced and affordable prevention, treatment and screening services for county youth. Maternal and Infant Health: The pregnancy rate for females ages 15-44 increased from 2004-2006; Orange County s rate remains above that for the HVR and Upstate. The percentage of women who are receiving early prenatal care is well below HP2010 targets, and is lowest in teens, minority females, and geographically, in the cities of Middletown and Newburgh. Birth rates were relatively constant from 2004-2006, and are, like pregnancy rates, higher than the average for the HVR and Upstate. Birth rates are highest in Hispanic females. The city of Middletown has the highest birth rate in the county; the city of Newburgh has the highest percentage of births to teens (ages 17 and under) and Medicaid/Self Pay births. Infant mortality rates in the county have declined substantially since 2004, and the 2006 rate met the HP 2010 target for the first time. Infant mortality (as a percentage of total births) is highest in Black/African American infants, which is consistent with state and national findings. Orange County has the second lowest rate of LBW in the HVR; within the county rates are highest in teens and in Black/African Americans. Injuries: Overall mortality from unintentional injury or accidents in the County is higher than the HVR and NYS. This is in part due to death rates from motor vehicle accidents (MVAs) which are higher than the HVR, Upstate, and NYS. Rates of alcohol-related MVAs exceeded average rates for the region and for NYS in 2004-2006. Disease Control: The number of cases of certain sexually transmitted diseases (STDs), in particular Gonorrhea and Chlamydia has recently increased; a significant proportion of these cases are in adolescents and demonstrate the need for enhanced prevention services, screening and treatment in high risk groups. The case rate for HIV/AIDS is below that for Upstate and NYS. Advances in HIV treatment have dramatically reduced AIDS mortality, and advances in testing, such as highly accurate oral testing, will hopefully increase testing acceptance and frequency in high risk groups. Enhancements to disease surveillance systems instituted by OCDOH permit closer monitoring for all reportable communicable diseases, including TB and vaccine preventable diseases. The recent resurgence in Pertussis cases in the county in children and adolescents is testimony of the need to achieve full protection from vaccine preventable diseases through timely and complete immunization. Full protection of county residents at highest risk from serious illness from influenza and pneumonia remains a priority; efforts have been intensified with the arrival of pandemic H1N1 influenza. The rate of Lyme disease is Orange County Community Health Assessment 2010-2013 2

high in the county as it is in several counties in the HVR, exceeds HP 2010 targets, and remains a challenge. Rates for several enteric diseases, most notably Salmonellosis and Shigellosis, also require close monitoring and follow-up in the communities where outbreaks occur. OCDOH continues to enhance surveillance systems for the rapid notification of any unusual disease symptoms suggestive of bioterrorism and for monitoring of influenza-like illness. Chronic Diseases: Although the mortality rates from cardiovascular diseases and cancer have declined in recent years in county residents, categorically these diseases still account for the majority all adult deaths in Orange County. Mortality rates from all causes and cardiovascular diseases are higher in minorities than non-minorities in the county, and patterns suggest higher rates of mortality in geographic areas with higher poverty levels and minority populations (the county s cities). Analysis of NYSDOH Prevention Quality Indicator health composites indicate excess hospital admission rates in the county s three cities related to certain chronic diseases. Comparative mortality rates from all cardiovascular diseases in the county for 2004-2006 are below those for Upstate and NYS and slightly above HVR rates. Smoking is a major risk factor for cancer, cardiovascular diseases, and chronic respiratory conditions; obesity is strongly linked with development of cardiovascular disease and breast cancer. Survey findings from the 2003 NYSDOH Expanded Behavioral Risk Factor Surveillance System (EBRFSS) indicate rates of smoking and obesity in county residents ages 18 and over far in excess of HP 2010 targets. Provisional data from the 2008 EBRFSS suggest improvement in smoking rates by adults; however the prevalence of overweight and obesity in adults have not shown improvement. In terms of other chronic diseases, in 2004-2006 the diabetes mortality rate was above HVR, Upstate, and NYS rates. Comparatively higher mortality rates from cirrhosis in males and alcohol-related motor vehicle accidents in the county indicate the need for prevention and treatment programs and services related to alcohol abuse. Rates of hospitalization for asthma in children as well as in adolescents and adults exceed HP2010 targets for all ages except 15-24, and the average rate (all ages) was above that for NYS, the second highest in the HVR, and below that for NYS. Asthma mortality rates in county residents from 2004-2006 were the highest in the HVR, and well above those for Upstate and NYS. Incidence rates for cancer by site in county males and females were higher than those for the HVR and NYS for lung and bronchus, thyroid, and colorectal cancer; for females incidence rates were comparable to the HVR for breast cancer and higher than the HVR for cervical cancer. The incidence rate for prostate cancer was slightly higher than that the HVR and NYS rates. Overall cancer mortality rates in county residents have shown improvement from 2004-2006. Gender disparities in disease incidence and mortality are apparent for certain types of cancer and cardiovascular diseases - males are disproportionately affected by heart disease, cerebrovascular disease (stroke), and cancer of the lung and bronchus and colon; females are disproportionately affected by breast cancer. To reduce chronic disease incidence, prevalence, and mortality, access to preventive education, primary care, and early screening and detection services in the county should be expanded, especially for those at highest risk for health disparities - the uninsured, recent immigrants, minorities, and low income groups. Refer to Sections IV and V - Local Health Priorities and Opportunities for Action for a detailed summary of recommendations based on assessment findings. Orange County Community Health Assessment 2010-2013 3

ORANGE COUNTY COMMUNITY HEALTH ASSESSMENT 2010-2013 EXHIBIT LISTING SECTION ONE: POPULATIONS AT RISK A1. Demographic Information Exhibit 1A.1 Trends in Orange County Municipal Population, 1970-2000 (1970-2000 Census Comparisons, counts and percentage change) Exhibit 1A.2a A Slice of Orange Census 2000 Profile 1A.2b Annual Estimates of the Population for Minor Civil Divisions in New York, Listed Alphabetically Within County: April 1, 2000 - July 1, 2007 Exhibit 1A.3 Orange County Population Density Map, 2000 Exhibit 1A.4 Orange County Population Growth Map, 1990-2000 Exhibit 1A.5a-c Age Distribution by Municipality: Orange County, 1990-2000 (1990-2000 Census Comparisons, counts and percentage change) Exhibit 1A.6 Orange County Population by Gender and Age, 2000 (2000 Census counts and percentages) Exhibit 1A.7a Orange County Population Map by Municipality, Age, Race, and Ethnicity, 1990 and 2000 1A.7b Annual County Resident Population Estimates by Age, Race, and Hispanic Origin, July 2000 to July 2007 Exhibit 1A.8 Orange County Population by Single Race and Year, 1990-2000 (1990/2000 Census Comparisons, counts and percentage change) Exhibit 1A.9a-c Orange County Population by Municipality and Hispanic Origin, 1990-2000 (1990/2000 Census Comparisons, counts and percentage change) Exhibit 1A.10a-c White Population of Orange County by Age and Municipality, 1990-2000 (1990/2000 Census comparisons, counts and % change) Exhibit 1A.11a-c Hispanic/Latino Population of Orange County by Age and Municipality, 1990-2000 (1990/2000 Census comparisons, counts and % change) Exhibit 1A.12a-c Asian Population of Orange County by Age and Municipality, 1990-2000 (1990/2000 Census comparisons, counts and % change) Exhibit 1A.13a-c Black or African American Population of Orange County by Age and Municipality, 1990-2000 (1990/2000 Census comparisons, counts and % change) Exhibit 1A.14a Nativity and Region of Birth, Orange County Population, 1990-2000 1A.14b Foreign-Born Population by Zip Code, Orange County and Hudson Valley Region, 1990-2000 Exhibit 1A.15 Language Spoken at Home by Municipality: Orange County 2000 Exhibit 1A.16a-c Limited English Proficiency and Eligibility for Free or Reduced School Lunch by School District, 2007-2008 Exhibit 1A.17 Educational Attainment Persons 25 and Over by Municipality, 2000 Exhibit 1A.18 Orange County Families by Municipality and Income, 2000 Exhibit 1A.19 Orange County High School Graduates Receiving NYS Regents Diplomas by School District, 2006-2007 Exhibit 1A.20 Persons Below Poverty Level: Orange County, 2000 Exhibit 1A.21a-b Orange County Recipients of Financial and Medical Assistance by Type and Municipality, December 2008. Exhibit 1A.22 Orange County Department of Social Services Population Served, 2005-2008 Orange County Community Health Assessment 2010-2013 1

Exhibit 1A.23 Demographic Profile of Public School Districts in Orange County, 2007-2008 (Racial/Ethnic Composition, Attendance, Suspension, and Drop-Out Rates, Socioeconomic Indicators) Exhibit 1A.24a-b Poverty Status by Age, Race, Ethnicity and Household Type in Orange County, 2000 Exhibit 1A.25 Employed Persons 16 and Over by Municipality and Occupation: Orange County, 2000 Exhibit 1A.26a-d Selected Housing Characteristics in Orange County by Municipality, 2000 (Count and percentages of: owner occupied units, renter-occupied units, pre-1950 housing units, over 1 occupant per room, owner/renter costs of 30% + household income) Exhibit 1A.27 Projected Population of Orange County 2005-2025 Exhibit 1A.28 Orange County Preliminary Population Projections by Age and Gender, 2005-2035 Exhibit 1A.29 Orange County Regional Comparisons, 2000 (Population by Age and Race/Employment & Poverty) Exhibit 1A.30 Orange County Regional Comparisons, 2000 (Income & Educational Attainment/Median Family Income/Percent Aged 25+ with a College or Graduate Degree) Exhibit 1A.31 Orange County Municipalities by Zone, 2009 Exhibit 1A.32 Orange County Municipalities by Zip Code, 2009 A2. Health Status Information Leading Causes of Death and Mortality Rates Exhibit 1A.33a-c Mortality from All Causes by Gender, Ethnicity, Race, Age, and Zone, Orange County and Upstate NY, 1998-2006 Exhibit 1A.34 Top 10 Causes of Death, Orange County, Upstate NY, and NYS, 2005-2007 Exhibit 1A.35 Number of Deaths from Leading Causes, Ranked within Age Groups, by Gender, Orange County, 2004-2006 Family Health Exhibit 1A.36a-e Hospital Discharge Rates for Ambulatory Care Sensitive (ACS) Conditions (Ages 0-4, 5-14), Orange County, Hudson Valley Region, and NYS, 2004-2006 (Includes Asthma, Gastroenteritis, Otitis Media, and Pneumonia) ACS Conditions Ages 0-4 and Asthma Ages 5-14, Ten Year Time Trends, Orange County and Upstate NY, 1997-2006 Exhibit 1A.37 Percentage of Children Screened At or Around Age Two Years by County: 2002 Birth Cohort (2003-2005 Blood Lead Test Data), New York State Excluding New York City (Map) Exhibit 1A.38 Incidence Rate of Blood Lead Levels > 10 mcg/dl Among Children Under Six Years by County: Three Year Average Rates, 2003-2005, New York State Excluding New York City (Map) Exhibit 1A.39 Selected Kids Well-Being Indicators, Orange County and Rest of State, 2003-2007 Exhibit 1A.40 Death Rates in Children and Adolescents, Orange County, Hudson Valley Region, and NYS, 2004-2006 Exhibit 1A.41 Suicide and Self-Inflicted Injury Mortality and Hospital Discharge Rates (All Ages, Ages 15-19), Orange County, Hudson Valley Region, and NYS, 2004-2006 Exhibit 1A.42a-c Teenage Pregnancy Rates by Age Group (10-14), (15-17), (15-19), Orange County and Upstate NY, Ten Year Time Trends, 1997-2006 Exhibit 1A.43 Teenage Pregnancy Rate by Age Group (Ages 10-14, 15-17, 18-19), and Induced Termination of Pregnancy (ITOPS) to Pregnancy Ratio (All Ages) Orange County, Hudson Valley Region, and NYS, 2004-2006 Exhibit 1A.44a-c Teenage Birth Rates by Age Group (10-14), (15-17) (15-19), Orange County and Upstate NY, Ten Year Time Trends, 1997-2006 Exhibit 1A.45 Teenage Births (Age 15-17) - Percentage per 100 Live Births, Orange County and Upstate NY, Ten Year Time Trends 1997-2006 Orange County Community Health Assessment 2010-2013 2

Exhibit 1A.46a-d Births to Teen Mothers (17 years of age and younger) per 100 Live Births by Race, Ethnicity, Age and Zone, Orange County, 1998-2006 Exhibit 1A.47a-d Medicaid/Self-Pay Births Percentage per 100 Live Births, by Race, Ethnicity, Age and Zone, Orange County, 1998-2006 1A.47e Medicaid/Self Pay Births Percentage per 100 Live Births, 1998-2006 Exhibit 1A.48a-d Births with Early (First Trimester) Prenatal Care by Race, Ethnicity, Age and Zone, Orange County, 1998-2006 1A.48e Births with Early (First Trimester) Prenatal Care Percentage per 100 Live Births, Orange County and Upstate NY, Ten Year Time Trends, 1997-2006 Exhibit 1A.49a-d Births with Late (Last Trimester, No Care) Prenatal Care by Race, Ethnicity, Age and Zone, Orange County, 1998-2006 1A.49e Births with Late (Last Trimester, No Care) Prenatal Care Percentage per 100 Live Births, Orange County and Upstate NY, Ten Year Time Trends, 1997-2006 Exhibit 1A.50a-d Early Gestational Age Births (< 37 weeks gestation) by Race, Ethnicity, Age and Zone, Orange County, 1998-2006 1A.50e Short Gestation Births (< 37 weeks gestation) per 100 Live Births, Orange County and Upstate NY, Ten Year Time Trends, 1997-2006 Exhibit 1A.51a-d Low Birthweight Births (<2500 grams), by Race, Ethnicity, Age and Zone, Orange County, 1998-2006 1A.51e Low Birthweight Births (<2500 grams) Percentage Births per 100 Live Births, Orange County and Upstate NY, Ten Year Time Trends 1997-2006 Exhibit 1A.52 Pregnancy Rates, Females Age 15-44, Orange County and Upstate, Ten Year Time Trends, 1997-2006 Exhibit 1A.53a Birth Rates by Maternal Race, Ethnicity, Age and Zone, Orange County, 1998-2006 1A.53b Birth Rate (Ages 15-44), Orange County and Upstate NY, Ten Year Time Trends 1997-2006 Exhibit 1A.54 Maternal Mortality Rates, Orange County, Hudson Valley Region, and NYS, 2004-2006 Exhibit 1A.55 Infant Mortality Rates by Race, Ethnicity, and Zone, Orange County 1998-2006 Exhibit 1A.56 Neonatal Mortality Rates by Race and Ethnicity, Orange County, 1998-2006 Exhibit 1A.57 Post Neonatal Mortality Rates, Orange County, 1998-2006 Exhibit 1A.58 Infant Mortality Rates, Orange County and Upstate NY, Ten Year Time Trends, 1997-2006 Exhibit 1A.59 Neonatal Mortality Rates, Orange County and Upstate NY, Ten Year Time Trends, 1997-2006 Exhibit 1A.60 Post-Neonatal Mortality Rates, Orange County and Upstate NY, Ten Year Time Trends, 1997-2006 Exhibit 1A.61 Very Low Birthweight (<1,500 grams) Births, Orange County, Hudson Valley Region, Number and Percentage per 100 Live Births, 2004-2006 Exhibit 1A.62 Newborn Drug-Related Discharges, Orange County, Hudson Valley Region, and NYS, 2004-2006 Exhibit 1A.63 Comparison of Domestic Violence Reporting and Arrest Rates in New York State, Analysis of the 1997 and 2000 Domestic Incident Statistical Databases Domestic Violence Reporting Practices by County Exhibit 1A.64 Homicide Mortality, Orange County, Hudson Valley Region, and NYS, 2004-2006 Exhibit 1A.65a-b Mortality from Total Accidents by Gender, Ethnicity, Race, Age, and Zone, Orange County and Upstate NY, 1998-2006 Exhibit 1A.66 Discharge Rates from Unintentional Injury by Age, Orange County, Hudson Valley Region, and New York State, 2004-2006 Exhibit 1A.67 Mortality Rates from Unintentional Injury by Age, Orange County, Hudson Valley Region, and New York State, 2004-2006 Exhibit 1A.68 Mortality from Motor Vehicle Accidents, Total and Alcohol-Related, Orange County, Hudson Valley Region, and New York State, 2004-2006 Orange County Community Health Assessment 2010-2013 3

Exhibit 1A.69 Exhibit 1A.70 Mortality from Motor Vehicle Accidents, Orange County and Upstate New York, Ten Year Time Trends, 1997-2006 Discharge Rates for Traumatic Brain Injury, Orange County, Hudson Valley Region, and Upstate, 2004-2006 Disease Control Communicable Disease Exhibit 1A.71 Cases and Rates of Early Syphilis, (All Ages, Ages 15-19), and Congenital Syphilis, Orange County, Hudson Valley Region, and NYS, 2004-2006 Exhibit 1A.72 Cases and Rates of Gonorrhea, (All Ages, Ages 15-19), Orange County, Hudson Valley Region and NYS, 2004-2006 Exhibit 1A.73 Cases and Rates of Chlamydia by Gender, Race, Ethnicity, and Age, Orange County, Hudson Valley Region, and NYS, 2004-2006 Exhibit 1A.74 Discharge Rates for Pelvic Inflammatory Disease, Orange County, Hudson Valley Region, and NYS, 2004-2006 Exhibit 1A.75a Cases and Rates of AIDS, Orange County, Hudson Valley Region and NYS, 2004-2006 1A.75b Cases and Rates of HIV Infection, Orange County, Hudson Valley Region, and Upstate NY, 2000-2006 1A.75c Persons Living with AIDS and HIV Infection by Gender, Ethnicity, Race, and Age, and Mode of Transmission/Risk Category, Orange County, Ryan White Mid- Hudson Region, and Upstate NY, Cumulative to 2006. Exhibit 1A.76a Trends in AIDS Mortality, Orange County and Upstate NY, Ten Year Time Trend, 1997-2006 1A.76b Trends in AIDS Mortality Orange County, Hudson Valley Region, and NYS, 1997-2006 Exhibit 1A.77 HIV Positive Newborns, Orange County, Hudson Valley Region, and NYS, 2001-2003 Exhibit 1A.78a Cases and Rates of Tuberculosis in Orange County, Hudson Valley Region, and Rest of NYS, 2004-2006 1A.78b Cases and Rates of Tuberculosis by Gender, Ethnicity and Race, Orange County, Hudson Valley Region, and Upstate NY, 1998-2006 Exhibit 1A.79 Total Cases and Rates of Selected Reportable Communicable Diseases, Orange County, Hudson Valley Region, and Rest of NYS, 2004-2006 Disease Control Chronic Disease Exhibit 1A.80 Mortality from Pneumonia by Gender, Ethnicity, Race, Age, and Zone, Orange County and Upstate NY, 1998-2006 Exhibit 1A.81 Mortality from Cardiovascular Disease by Gender, Ethnicity, Race, Age, and Zone, Orange County and Upstate NY, 1998-2006 Exhibit 1A.82a-c Trends in Cardiovascular, Cerebrovascular, and Diseases of the Heart Mortality, Orange County, 1997-2006 Exhibit 1A.83a Admission Rates for Prevention Quality Indicators for Orange County Adult Population, 2005-2006 1A.83b Discharge Rates for Diseases of the Heart, Cardiovascular Disease, and Cerebrovascular Disease by Gender, Orange County, Hudson Valley Region and Upstate NY, 2004-2006 Exhibit 1A.84a-b Mortality from Diseases of the Heart by Gender, Ethnicity, Race, Age, and Zone, Orange County and Upstate NY, 1998-2006 Exhibit 1A.85a-b Mortality from Cerebrovascular Disease by Gender, Ethnicity, Race, Age, and Zone, Orange County and Upstate NY, 1998-2006 Exhibit 1A.86 Cancer Incidence and Mortality Rates from all Causes by Gender, Orange County, 2001-2005 Exhibit 1A.87 Trends in Cancer Incidence and Mortality Rates by Gender, Orange County and NYS, 1976-2005 Orange County Community Health Assessment 2010-2013 4

Exhibit 1A.88a Age-Adjusted Cancer Incidence Rates by Site and Gender, Orange County, 2001-2005 1A.88b Discharge Rates for Neoplasms by Gender, Orange County, Hudson Valley Region, and Upstate NY, 2004-2006 Exhibit 1A.89a-c Mortality from Malignant Neoplasms by Gender, Ethnicity, Race, Age, and Zone, Orange County and Upstate NY, 1997-2005 Exhibit 1A.90 Lung and Bronchus Cancer, Incidence and Mortality Rates by Gender, Orange County, Hudson Valley Region, and NYS, 2001-2005 Breast Cancer, Incidence and Mortality Rates, Orange County, Hudson Valley Region, and NYS, 2001-2005 Cervical Cancer, Incidence and Mortality Rates, Orange County, Hudson Valley Region, and NYS, 2001-2005 Exhibit 1A.91a-e Trends in Mortality Rates from Cancer: Lung and Bronchus, Breast, Cervical, Colorectal, and Oral, Orange County and Upstate NY, 1997-2006 Exhibit 1A.92 Colorectal Cancer, Incidence and Mortality Rates by Gender, Orange County, Hudson Valley Region, and NYS, 2001-2005 Prostate Cancer, Annual Incidence and Mortality Rates, Orange County, Hudson Valley Region, and NYS, 2001-2005 Oral Cavity and Pharyngeal Cancer, Incidence and Mortality Rates by Gender, Orange County, Hudson Valley Region, and NYS, 2001-2005 Exhibit 1A.93a-b Mortality from Diabetes by Gender, Ethnicity, Race, Age, and Zone, Orange County and Upstate NY, 1998-2006 Exhibit 1A.94* Discharge Rates for Diabetes by Gender, Orange County and Upstate NY, 2004-2006 Exhibit 1A.95a-b Mortality from COPD/CLRD by Gender, Ethnicity, Race, Age, and Zone, Orange County and Upstate NY, 1998-2006 Exhibit 1A.96 Discharge Rates for COPD/CLRD by Gender, Orange County and Upstate NY, 2004-2006 Exhibit 1A.97 Trends in Asthma Mortality, Orange County and Upstate NY, 1997-2006 Exhibit 1A.98a-b Mortality from Cirrhosis of the Liver by Gender, Ethnicity, Race, Age, and Zone, Orange County and Upstate NY, 1998-2006 Exhibit 1A.99 Discharge Rates for Cirrhosis of the Liver by Gender, Orange County and Upstate NY, 2004-2006 B. Access to Care Exhibit 1B.1 Hospital/Medical Center Services in Orange County New York, 2009 Exhibit 1B.2 Hospital/Medical Center Service Statistics: Orange County New York, 2008 Exhibit 1B.3 Community Health Center Services in Orange County New York, 2009 Exhibit 1B.4 Hospital/Medical Center and Community Health Center Locations in Orange County New York, 2009 Exhibit 1B.5 Certified Home Health Agencies and Long Term Home Health Care Programs in Orange County New York, 2009 Exhibit 1B.6 Nursing Facilities in Orange County New York, 2009 Exhibit 1B.7 Managed Care Plans in Orange County New York, 2009 Exhibit 1B.8 Expanded BRFSS Access to Care Results, Orange County, Hudson Valley Region, and NYS, 2003 Orange County Community Health Assessment 2010-2013 5

C. Behavioral Risk Factors Exhibit 1C.1 Expanded BRFSS Results for Core Modules, Orange County, Hudson Valley Region and Rest of NYS, 2003, with HP 2010 comparisons (Includes: Health Status/Healthy Days, Health Care Access, Exercise, Diabetes, Asthma, Arthritis, Tobacco Use, Tobacco ETS, Alcohol Consumption, Mammography, Sexual Behavior, Family Planning, Cardiovascular Disease, Prostrate Cancer Screening, Colorectal Screening) Exhibit 1C.2 Expanded BRFSS Results for Optional Modules, Orange County, Hudson Valley Region and Rest of NYS, 2003, with HP 2010 comparisons (Includes: Cholesterol Awareness, Disability, Nutrition, Hypertension Awareness, Injury Control (Falls), Immunization, Oral Health, Weight Control, and Women s Health) Exhibit 1C.3 Adolescent/Young Adult Suicide (Age 15-19) Annual Death Rate Per 100,000 Residents Ages 15-19, 2004-2006 Exhibit 1C.4a-b Youth Risk Indicator Rates, 2002 D. The Local Health Care Environment Exhibit 1D.1 Regional Perspective Map SECTION TWO: LOCAL HEALTH UNIT CAPACITY PROFILE Exhibit 2.1a-h Orange County Department of Health Organization Charts, 2009 Exhibit 2.2 Orange County Departmental Program Listing and Contact Numbers, 2009 Exhibit 2.3 Orange County Department of Health Intervention Services Schedule, 2009 Exhibit 2.4 Orange County Department of Health Clinic Services Schedule, 2008-2009 Exhibit 2.5 Orange County Department of Health FTEs by Division, 2009 SECTION THREE: PROBLEMS AND ISSUES IN THE COMMUNITY Exhibit 3.1 Resource Guide for Health and Related Services, Orange County, 2009 Exhibit 3.2 Listing of OCDOH Staff Community Affiliations, 2009 SECTION FOUR: Exhibit 4.1a-b Exhibit 4.2a-e Exhibit 4.3 LOCAL HEALTH PRIORITIES Orange County Department of Health Community Agency/Provider and Resident/Health Consumer Local Health Needs Survey Forms, 2009 CHA Community Health Town Meeting Regions CHA Prevention Agenda Workgroup Roster Orange County Community Health Assessment 2010-2013 6

SECTION ONE: POPULATIONS AT RISK LIST OF FIGURES Figure 1 Top 10 Leading Causes of Death in Orange County, New York, 2005-2007 Figure 2 Children Age 19-35 Months That Are Fully Immunized (4:3:1:3:3), New York State, 2000-2006 Figure 3 Orange County Infant Mortality Rate per 1,000 Live Births, 1997-2006 Figure 4 Orange County Cardiovascular Disease Death Rate per 100,000 Population, 1997-2006 Figure 5 Orange County Diseases of the Heart Death Rate per 100,000 Population, 1997-2006 Figure 6 Orange County Cerebrovascular Disease (Stroke) Death Rate per 100,000 Population, 1997-2006 Figure 7 Orange County Female Breast Cancer Death Rate per 100,000 Female Population, 1997-2006 Figure 8 Orange County Diabetes Death Rate per 100,000 Population, 1997-2006 Figure 9 Core Behavioral Risk Factors Overview Figure 10 Current Use of Cigarettes Among Middle and High School Students by Region, New York State, 2000-2006 Figure 11 Percent of Women Who Smoked During the Last 3 Months of Pregnancy, New York State (Excluding New York City), 1995-2003 Figure 12 Binge Drinking Among Adults Aged 18 Years or Older, New York State, 1995-2003 Figure 13 High School Students Reporting Binge Drinking During the Past Month, New York State, 1997-2003 Figure 14 Adults (aged 18 years and older) Who Have Been Told They Have High Blood Cholesterol: New York BRFSS, 1991-2001 Figure 15 Adults (aged 18 years and older) Who Have Been Told They Have High Blood Pressure: New York BRFSS, 1991-2001 Figure 16 NYSDOH Oral Health Survey of Third Grade Children Summary Results For Orange County, 2003 SECTION TWO: LOCAL HEALTH UNIT CAPACITY PROFILE Figure 1 CHAA/LTHHCP Major Diagnostic Categories by Year, 2007-2008 Figure 2 CHAA/LTHHCP Visits by Year by Discipline, 2004-2007 Figure 3 Tuberculosis Control Program Tests and Cases, 2004-2008 Figure 4 Total Annual Visits, OCDOH STD Clinics, 2004-2008 Figure 5 Sexually Transmitted Disease Cases by Year, 2004-2008 Figure 6 HIV Case Interviews and Partners Identified for Notification, 2004-2008 Figure 7 HIV Clinic Visits by Year, 2004-2008 Figure 8 Immunization Program Vaccinations, 2004-2008 Figure 9 Early Intervention Clients and Costs, 2003-2008 Figure 10 Preschool Special Education Clients and Costs, 1994-2004 Figure 11 Early Intervention and ICHAP Referrals and Active Cases, 2003-2008 Figure 12 ATUPA 5 Year Comparison, 2003-2008 Orange County Community Health Assessment 2010-2013 7

GUIDE TO STATISTICAL TERMS Weight Statistics Underweight is defined as less than 5th percentile based on the 2000 CDC growth chart percentiles for weight-for length for children under 2 years and a body mass index (BMI)-for-age for children 2 years and older. Overweight is defined as less than or equal to the 95th percentile based on the 2000 CDC growth chart percentiles for BMI-for-age. Pregnancies Pregnancies are the sum of the number of live births, induced terminations of pregnancies, and fetal deaths (20+ weeks gestation). Pregnancy rates are the number of pregnancies in a particular age group per 1,000 females in that same age group. Birth Rates Birth rates are the annual number of live births to women in a particular age group per females in that same age group. Induced Abortion to Birth Ratio This is computed by dividing the number of induced terminations of pregnancy by the number of live births and then multiplying by 100. Mortality Rates The mortality rates are rates per 100,000 population with the exception of work related mortality. Work related mortality is per 100,000 employed (Number employed provided by the NYS Department of Labor). Both crude and age adjusted rates are presented. Hospitalization Rates The rates presented are per 100,000 persons in a specific age group or the total population. Birth and Death Related Indicators Information is extracted from birth, death and fetal death certificates. Race is categorized as White, Black and Other. Total includes race not stated. Hispanic is a separate count equal to Hispanic White, Hispanic Blacks, Hispanic Others and Hispanic Not Stated. When percentages are calculated records with missing information for the indicator of interest are excluded from the calculation. The following are definitions of these indicators: Infant Mortality: number of deaths less than 1 year of age per 1,000 live births. Neonatal Mortality: number of deaths less than 28 days old per 1,000 live births. Postneonatal Mortality: number of deaths between 28+ days old and under 1 year of age per 1,000 live births. Orange County Community Health Assessment 2010-2013 Guide to Statistical Terms 1

Spontaneous Fetal Deaths (20+ weeks gestation) - Spontaneous fetal death rate is the number of spontaneous fetal deaths (gestation 20 weeks or more) per 1,000 spontaneous fetal deaths (gestation 20 weeks or more) plus live births. Low Birthweight Births - Low birthweight births are the number of infants born weighing less than 2500 grams. Very Low Birthweight Births - Very low birthweight births are the number of infants born weighing less than 1500 grams. Prematurity Rate - Prematurity rate is the percent of infants born before 37 weeks gestation. Maternal Mortality Rate - Maternal mortality rate is the number of deaths due to complications of pregnancy, childbirth and puerperium (ICD-9 codes 630-676 before 1999 or ICD-10 codes O00- O99 in 1999 or later) per 100,000 live births. Early Prenatal Care - Early prenatal care is the number of births to women who began prenatal care within the first three months of pregnancy (first trimester). Late or No Prenatal Care - Late or no prenatal care is the number of births to women who began prenatal care within the last 3 months of pregnancy (3rd trimester) or not at all. AIDS Case Rate AIDS case rates are presented as rates per 100,000 population. Newborn HIV Seropositive Rate The seropositive rate is the percent of positive results. The presence of HIV antibodies in newborns indicates infection of the mother and not necessarily infection of the infant. Syphilis and Gonorrhea Early Syphilis includes any of the first three stages of syphilis (primary, secondary or latent of less than 1 year duration). Congenital syphilis is passed from mother to infant during pregnancy. Rates for syphilis and gonorrhea are rates per 100,000 population. Congenital syphilis rates are per 10,000 births. Orange County Community Health Assessment 2010-2013 Guide to Statistical Terms 2

2010-13 Community Health Assessment COVER PAGE County: Orange Local Health Department Address: 124 Main Street, Goshen, New York 10924 Telephone: 845-291-2332 Fax: 845-291-2341 Submitted by: Jean M. Hudson, M.D., M.P.H. E-MAIL: JMHudson@orangecountygov.com Prepared by: CHA Development Team GENERAL COUNTY INFORMATION Health Department Type (please check one): Full Service Less than Full Service Organization Type (please check one): Single Agency Multiple Agency, (Health Only) please list: 1

2010-13 Community Health Assessment CHA Prevention Agenda Description and Priority Areas This form provides a summary of the Prevention Agenda activities and priorities, which are described in more detail within the CHA document. 1. With whom did you partner to establish the 2-3 Prevention Agenda priority areas? Please check all that apply and where lines are provided, list partners: X Hospitals: Bon Secours Charity Health System (3 sites) Orange Regional Medical Center (2 sites) St. Luke s/cornwall Hospital (2 sites) X CBOs: Occupations; Maternal-Infant Services Network; Independent Living; Mobile Life; Volunteer EMS Services; Home Care, Adult Day Care, and Assisted Living Agencies; Safe Homes; Safe Harbors; and Breast Cancer Options. X X X Other local government agencies: Office for the Aging, Department of Social Services, Department of Mental Health, Youth Bureau, Child Protective Services, Municipal EMS Services, and Municipal Department of Human Services and Senior Services. Not for Profits: Greater Hudson Valley Family Health Care, Hudson River Health Care,Middletown Community Health Centers, YMCA, YWCA, Head Start,and TASA. Other LHDs, please list: All Hudson Valley Region LHDs (Collaborative Regional Health Survey of Local Health Needs): Dutchess, Putnam, Rockland, Sullivan, Ulster, and Westchester. X Primary/medical care providers X Schools X Faith organizations HMOs X Businesses X Rural Health Networks (MISN) X Others: County Legislators, Town Supervisors, Board of Health Members, Local Police Departments. 2. What are the 2-3 priority areas your collaborative has selected, please check: X Access to Quality Health Care Tobacco Use X Health Mothers/Babies/Children Physical Activity/Nutrition Unintentional Injury Healthy Environment X Chronic Disease Infectious Disease Community Preparedness Mental Health/Substance Abuse 2

2010-13 COMMUNITY HEALTH ASSESSMENT County: Orange 3. Did your collaborative use the services of a contractor to assist you in the process you used to arrive at your priority areas? Y/N Please provide their contact information: Mary L. Bevan, M.P.H, Public Health Consultant mlbgrants@earthlink.net 4. What was your collaborative process? Check all that apply: X In-person meetings X Phone calls X Conference calls X Other Regional Health Town Meetings Please briefly describe your process: Several integrated strategies were used to facilitate and invite agency, health care provider, and community input in establishing local health priorities. The first strategy was ongoing communication with and consultation from the community collaborators listed in Section III, Exhibits 3.1 and 3.2. OCDOH representatives meet with these groups regularly to discuss community-based health initiatives and emerging health and service delivery needs. In addition, two versions of a regional survey of local health needs were developed collaboratively with representatives from all HVR counties with assistance from health researchers at New York Medical College School of Public Health. The surveys were administered in the community and online via the County s website to solicit input on local health needs from a diversity of community-based health providers, community agencies, and residents. As part of the local health priority identification process, OCDOH and local hospital leads co-convened Health Town Meetings in each of the county s 4 health planning regions, to gain further input and insight of health needs at the community level. These meetings were hosted by the hospital or medical center based each region. Town meetings included an overview of the CHA/CSP process, Prevention Agenda Priorities, and discussion of leading health indicators in each priority area. 5. Please indicate the individuals from your agency who were involved in the process. Check all that apply. X Local Public Health Director/Commissioner X Nurses X Supervising X Line/program X Sanitarians/environmental engineers X Physicians/PAs X Community Planners X Health Educators X Others, please provide title: Nurse Epidemiologist & SUNY Albany SPH Epidemiology Fellow 6. Were any of the following individuals involved in the process? Board of Health member(s) X Y N Member(s) of the county legislature X Y N County Executive/Administrator X Y N 3

2010-13 COMMUNITY HEALTH ASSESSMENT County: Orange CHA CHECKLIST/ INDEX This checklist/index identifies the elements of a comprehensive CHA as described in the Guidance and Format Document. The checklist should be used as a companion to the Guidance and Format Document, which provides greater detail than does the checklist. The checklist has many uses: it will show the portions of the CHA that have been included, identifying the page locations for the material submitted; it provides a reference for all the activities undertaken to support community health assessment; it provides a quick reference for responding to inquiries and making updates; it will also assist us in identifying potential technical assistance and training needs. Please use the following conventions for the lines preceding the sections and sub - sections: X - to denote information provided N/A - to denote information that is not available N/S - to denote information that is not submitted Please use the index to identify the placement of the information within the CHA document, whether you follow the order of the checklist or use another format. If you have any questions please contact Lucy Mazzaferro at (518) 473-4223. Reminder Please note that data for all service areas defined by Article 6 must be reflected in the CHA. Data related to all optional or optional other program areas must also be included in the CHA. This means that data for the five Basic Service areas and the program areas within those categories must be included in the CHA. The CHA forms the justification for the activities conducted in the MPHSP and any activities undertaken by the LHD, for which reimbursement is sought, must be justified by the data analysis in the CHA. A listing of the Service and Program Areas has been included for your use. CHA Checklist/INDEX INDEX (page no.) X Section One - Populations at Risk 1-44 X A. Demographic and Health Status Information narrative and statistical description of the county 1-23 x_ 1. overall size 1-5 x_ 2. breakdowns by a) x age 1-5 b) x sex 1-5 c) x race 1-5 d) _ x income levels (esp.percent at poverty level) 1-5 e) x percent employed 1-5 f) x educational attainment. 1-5 g) x_ housing 1-5 h) x_ other relevant characteristics 1-5 _x_ 3. natality 1-5 _x_ 4. morbidity 5-23 4

2010-13 COMMUNITY HEALTH ASSESSMENT County: Orange _x_ 5. mortality 5-23 _x_ 6. other relevant demographic data compiled and analyzed, using small areas, such as minor civil divisions, zip codes or census tracts within counties, wherever possible and meaningful..1-23 _x_ 7. particular emphasis placed on interpreting demographic trends for the relationship to poor health and needs for public health services. 5-23 For your convenience, a listing of service areas and programs has been included. Please note, that the CHA does not require data for environmental health programs. If the LHD is performing environmental health programs that are not described in 10NYCRR40-2 or 3 please include the data in support of those programs. The basic service area program and services are discussed throughout Section I-IV of the report; OCDOH major programs and services are described in Section II (S2). Basic Service Area: Family Health Programs: _x_ Dental Health Education (S2) 1-20 _x_ Primary and Preventive Health Care Services. (S2) 1-20 _x_ Lead Poisoning. (S2) 1-20 _x_ Prenatal Care and Infant Mortality...(S2) 1-20 _x_ Family Planning (S2) 1-20 _x_ Nutrition.. (S2) 1-20 _x_ Injury Prevention. (S2) 1-20 Basic Service Area: Disease Control Programs: _x_ Sexually Transmitted Diseases.. (S2) 1-20 _x_ Tuberculosis... (S2) 1-20 _x_ Communicable Diseases (S2) 1-20 _x_ Immunization.....(S2) 1-20 _x_ Chronic Diseases.... (S2) 1-20 _x_ Human Immunodeficiency Virus (HIV) (S2) 1-20 Optional Service Areas Dental Health Services... x_ Home Health Services.... (S2) 1-20 Optional Other Service Areas/Programs _x_ Medical Examiner... (S2) 1-20 Emergency Medical Services. Laboratories.. Please add any other programs not listed and provide the page number: X B. Access to Care general discussion of health resources..24-28 _x_ 1. Description of the availability of a) hospitals.24-26 5

2010-13 COMMUNITY HEALTH ASSESSMENT County: Orange b) clinics 24-26 c) private providers 24-26 d) information about access to health care providers 24-28 _x_ 2. Discussion of primary care and preventive health services utilization (Possible date source: The Behavioral Risk Factor Survey) 24-28 _x_ 3. Discussion of commonly-identified barriers and affected sub-groups. 26-28 _x_ a) Financial barriers inadequate resources to pay for health care, inadequate insurance, Medicaid eligibility vs. Medicaid enrollment vs. access to providers... 26-28 _x_ b) Structural barriers insufficient primary care providers, service sites, or service patterns.. 26-28 _x_ c) Personal barriers the cultural, linguistic, educational, or other special factors that impede access to care... 26-28 X C. The Local Health Care Environment 41-44 _x_ 1. Identification and discussion of aspects of the environment that influence the attitudes, behaviors, and the risks of community residents for poor health within the following categories: a) _x_ physical.. 41-44 b) _x_ legal...... 41-44 c) _x_ social 41-44 d) _x_ economic..... 41-44 _x_ 2. Other components of the health-related environment include: a) _x_ institutions (e.g., schools, work sites, health care providers). 41-44 b) _x_ geography (e.g., air, water quality).. 41-44 c) _x_ media messages (e.g., TV, radio, newspapers).. 41-44 d) _x_ laws and regulations (smoking policies) 41-44 There is no need for a community health assessment that relates to regulatory environmental programs defined by 10NYCRR40-2 and 3. However, the need for additional environmental health programs conducted by the LHD must be substantiated by data analysis within the CHA. 6

2010-13 COMMUNITY HEALTH ASSESSMENT County: Orange X Section Two - Local Health Unit Capacity Profile - profile of staff and program resources available for public health activity in the county. (Suggested Resource: APEXPH) 1-38 _x_ 1. Profile of the local agency s infrastructure, includes: a) _x_ organization. 1-38 b) _x_ staffing and skill level.. 21-22 c) _x_ adequacy and deployment of resources 10-20 d) _x_ expertise and technical capacity to perform a community health assessment. 23 X Section Three - Problems and Issues in the Community 1-31 _x_ A. Profile of Community Resources - community resources available to help meet the health-related needs of the county. 1, 4-29 _x_ 1. Groups that may have the capacity and interest to work either individually or in collaboration with the local health unit to improve the health status of the community.... 1, 4-31 _x_ 2. Collaborative efforts on a) _x_ development of hospital community service plans (CSP) 1 b) _x_ assessments 1-3 c) _x_ collaborative planning processes 1-3, 30-31 _x_ 3. Assessment of services for: a) _x_ availability 1-31 b) _x_ accessibility 1-31 c) _x_ affordability 1-31 d) _x_ acceptability. 1-31 e) _x_ quality.. 1-31 f) _x_ service utilization issues such as: (1) _x_ hours of operation 1-31 (2) _x_ transportation 1-31 (3) _x_ sliding fee scales 1-31 (4) other 1-31 _x_ 4. Discussion of significant outreach or public health education efforts and whether they are targeted to the general population or identified high-risk populations.. 1-4, (S2) 1-20 _x_ 5. A summary of the available clinic facilities and private provider resources for Medicaid recipients should also be discussed. (Suggested resource: The PATCH model.) 4-31 7

2010-13 COMMUNITY HEALTH ASSESSMENT County: Orange _x_ B. Access to Care _x_ 1. Statewide, community-specific and/or locally-developed estimates for the prevalence of health risk behaviors can be used to identify and discuss population subgroups that are at increased risk due to unhealthy behaviors.. (S1) 29-40 _x_ 2. Local circumstances/barriers related to priority health concerns and/or disparities have been considered... (S1) 29-40 C. Profile of Unmet Need for Services _x_ 1. Identification and discussion of additions to and changes in services that will improve the health of the identified at-risk groups. 1-3 _x_ 2. Discussion of types of changes to better serve the target group (e.g., lower/no cost, better hours, transportation assistance, increased sensitivity to populations in need, language, increased acceptance of Medicaid, and integration and/or co-location of services).1-3 _x_ 3. Identification of gaps in services and their location (e.g., township, city or census tract)... 1-3 _x_ 4. Discussion of problems that might be encountered in providing these services. 1-3. X _x_ 5. Disease control program sections specifically assess needed changes to public health law and codes.. 1-3 Section Four - Local Health Priorities - describe new (or intractable) areas of public health which rank as high local priority identified by more recent Prevention Agenda or other collaborative efforts between the LHD, hospitals, and other community-based organizations, health care providers, consumers. 1-14 _x_ 1. List and description of 2-3 priorities under the Prevention Agenda. 1-4 _x_ 2. Listing and description of additional priorities..... 1-4 _x_ 3. Summary of the process for public health priority(ies) identification: a) _x_ how recent.. 1-3 b) _x_ who was involved. 1-3 c) _x_ how were priorities determined.... 1-3 8

2010-13 COMMUNITY HEALTH ASSESSMENT County: Orange 4. Discussion of noteworthy accomplishment for both the LHD and other community public health partners 3-4 X Section Five - Opportunities for Action - building on all of the above sections, opportunities that the local health unit/department, solely or in partnership, can pursue are identified to alleviate the priority public health problems... 1-4 _x_ 1. Opportunities include the contribution/role played by: a) _x_ community-based organizations 1-4 b) _x_ businesses.. 1-4 c) _x_ labor and work sites.1-4 d) _x_ schools...1-4 e) _x_ colleges and universities 1-4 f) _x_ government 1-4 g) _x_ health care providers.1-4 h) _x_ health care insurers 1-4 i) _x_ the food industry 1-4 j) _x_ the media 1-4 (These actions would not have to be implemented by the LHD alone or at all. These actions are proposed so members or groups within the community might seize the opportunity to implement these activities or other activities that could reduce or eliminate the priority public health issue(s).) X Appendix A Community Report Card (Section Six) 1-7 _x_ A. Report card attached 2-7 _x_ B. Explanation of document distribution 1 9

ORANGE COUNTY COMMUNITY HEALTH ASSESSMENT 2010-2013 SECTION ONE: POPULATIONS AT RISK A. DEMOGRAPHIC AND HEALTH STATUS INFORMATION 1. The Population of Orange County A. Population Growth Rates and Density Countywide and By Municipality According to U.S. Census population estimates 1 published by the New York State Data Center, Orange County s population growth rate of 10.5% from Census 2000 (April 1, 2000) to July 1, 2007 was the highest in the state. (Empire State Development, NYS Data Center, County Population Table) Orange County ranks 12 th in population size of the 62 counties in New York. With 75% of its total population classified as urban, the once predominantly rural character of the county is changing. In 2007, there were an estimated 377,169 persons living in the county. Since 1970, the total county population has grown by approximately 70%. (Exhibit 1A.1, 1A.2a-b) The county occupies 816.4 square miles. Based on Census 2000, the average population density for cities in the county is 5,338 persons per square mile, for towns it is 383 persons per square mile, and for villages it is 2,645 per square mile. The population densities in the county s 42 communities range from a high of 11,944 in the village of Kiryas Joel to a low of 70 in the town of Tuxedo. The population density of the village of Kiryas Joel is more than twice the average for cities in the county. Newburgh, Orange County s most populated city, has the second highest population density of 7,398. (Exhibits 1A.2a, 1A.3) Orange County communities include 3 cities, 20 towns, and 19 villages. Nearly 18% of the county s total population resides in its 3 cities of Middletown, Newburgh and Port Jervis. Sixty-one percent (61%) live in its towns with the remaining 21% located in its villages. (Exhibit 1A.4) Rates of population growth vary by municipality and have more than doubled since 1970 in: the towns of Chester, Crawford, Greenville, Hamptonburgh, Monroe, Mount Hope, Wallkill and Woodbury; and the villages of Chester, Harriman, Maybrook, Montgomery, and Washingtonville. Municipalities with estimated population growth rates of twenty percent or more since Census 2000 include the towns of Minisink and Monroe and the villages of Kiryas Joel, Maybrook, and Montgomery. The community with the highest estimated rate of growth from 2000-2007 was the village of Kiryas Joel (59.8%). (Exhibit 1A.2a-b) 1 As the issuance date for the 2010-2013 CHA falls in the interim between decennial U.S. Censuses, population comparisons use Census 2000 (April 1, 2000) as the baseline compared with most recent population estimates (July 1, 2007). Additional information on the derivation of population estimate data is available at www.census.gov. B. Population Demographics Age, Gender, Race, Ethnicity, Nativity, Language, Educational Attainment, Income and Poverty Age and Gender Per Census 2000, the median age in Orange County increased from 1990 to 2000 by 3 years from 31.7 to 34.7. Based on 2007 population estimates, this has remained relatively constant at 34.6. Comparing Census data from 1990 to 2000, the largest increase in population occurred in the age range 45-54 (48.9%). The age range of 25-34 had the greatest decline at 18.5%. Based on 2007 population estimates, the greatest number of county residents fall in age range 25-54. (Exhibit 1A.5a-c, 1A.7b) Census 2000 documents the following trends in the age distribution in the county since 1990: a substantial increase in school age children (ages 5-17), a decline in the young adult population (ages 18-34), and an increase in the adult population 35-64, with the greatest increase in baby boomers in the age range 45-54. The number of persons ages 75 and older, especially those over the age of 85, has also continued to increase steadily. (Exhibit 1A.5a-c) The percentage of males and females in the county are similar until ages 65 and over, when the percentage of females in the population continues to increase, owing to the longer average lifespan in women. An exception to this is ages 15-24 where the proportion of males increases by several percentage points over the previous age intervals. This is most likely due to several factors the impact of the largely male cadet and graduate resident populations at the U.S. Military Academy at West Point and the group quarters population in the (3) state and federal male-only correctional institutions located within the county (1 Federal Correctional Institution (FCI) and 1 NYS facility in Otisville and 1 NYS facility in Warwick). (Exhibit 1A.6) Variations in median age by municipality are noteworthy. Certain municipalities exhibit significantly younger median ages than does the county as a whole (34.7). Kiryas Joel is a Hasidic community which was formed in 1977. Families are large (average number of persons per family is 5.8 vs. the county average of 3.4) and include a disproportionate number of young children, therefore the median age (15) in this community is much younger than in other communities. The village of Kiryas Joel is located in the town of Monroe, which influences the median age for this community as well (22.5). West Point Military Academy is located in the town of Highlands, and the Orange County Community Health Assessment 2010-2013 Section I 1

age of the cadet population contributes to lowering the median age in this community to 22.7. The city of Newburgh also has a lower median age (27.8) than the county, and the other two cities in the county, which may be attributed in part to its influx of recent immigrants, and a concentration of Hispanic/Latino families with younger children. The municipalities with the highest median ages include the town of Tuxedo (40.7), and the villages of Tuxedo Park (44.6) and Warwick (40). (Exhibit 1A.2a) Different patterns of demographic change have occurred in the county s municipalities. In general, the greatest number of residents in the county s municipalities was between 45 and 54 years old in 2000. The number of individuals in this age group has increased considerably (48.9%) since 1990. Similarly, the number of persons ages 85 and over has increased steadily (42.9%) in all the major municipalities since 1990. While the overall trend has been a slight increase in the percentage of the county s youngest population ages 0-4 (1.3%), this population has increased by 53.7% in the town of Monroe, and by 103.6% in the village of Kiryas Joel. In contrast, there has been a dramatic decline in the 0-4 population by more than one-third in the villages of Greenwood Lake, Harriman, Otisville, and Unionville. (Exhibit 1A.5a-c). Racial and Ethnic Composition In 2000, the county s single race composition was: 83.7% White, 8.1% Black/African American, 1.5% Asian and the remaining 6.7% classified as other. Persons of Hispanic/Latino ethnicity may be of any race. Hispanic/Latino ethnicity represented 11.6% of the county population. (Exhibit 1A.7a) From 1990-2000, the greatest rate of growth was in the Hispanic/Latino population which increased by 84.5%. The second highest increase was in the Asian population, which grew by 48.8%. During this time, the Black/African American population increased by 24.2% and the White population increased the least at 4.4%. (Exhibits 1A.8, 1A.9a-c) Orange County s race and ethnic composition based on U.S. Census 2007 population estimates is 84.8% White, 10.6% Black/African American, 2.4% Asian and 15.9% Hispanic/Latino. (Exhibit 1A.7b) Although the most prevalent racial category in Orange County is White, the total number and the proportion of White residents has increased at a slower rate in most municipalities since 1990. The number of White residents was 273,600 in 1990, and increased to 285,721 in 2000. In 2007 the estimated White population in Orange County was 319,812, representing an increase of nearly 12% since Census 2000. Note that for Whites the older adult population (85+) increased the most from 1990-2000, from 3,142 persons in 1990 to 4,413 persons in 2000, a 40.5% increase. The White population in the following age intervals declined from 1990 to 2000 under 5, 18-34 and 65-74. (Exhibit 1A.7a-b, 1A.10 a-c) In 2000, 39,738 persons in Orange County classified themselves as Hispanic/Latino, approximately 12% of the population; in 2007, the estimated Hispanic/Latino population increased to 59,791. This represents an increase of over 50% since Census 2000. Rank order for the top three communities in Hispanic/Latino population include the cities of Newburgh and Middletown and town of Wallkill. Many communities in the county have experienced an increase of 100% or more in their Hispanic/Latino populations from 1990 to 2000. It should be noted that there are inherent difficulties in complete enumeration of the undocumented Hispanic/Latino population in a governmental Census. While Hispanic/Latino residents in Orange County are from all over the world, in 2000 the largest number cited Puerto Rican ancestry, followed by Mexican. While increases in the Hispanic/Latino population occurred in every age group from 1990-2000, the greatest increases were in children ages 0-17, and in adults ages 35-54, 65-74, and 85 and over. (Exhibits 1A.7a-b, 1A.9a-c, 1A.11a-c) The Asian/Pacific Islander population in Orange County had the second highest rate of growth from 1990-2000 (from 3,549 in 1990 to 5,280 in 2000). In 2007, the Asian/Pacific Islander population was estimated to be 9,279, an increase of over 75% since Census 2000. This represents the highest rate of growth among racial and ethnic groups over the past 7 years. The Asian population is also concentrated in the communities of Newburgh (city), Middletown, and Wallkill, however there are significant populations in a number of other communities as well. The majority of Asian residents indicated their origins to be Asian Indian, Chinese, Filipino, and Korean. The Asian population increased in every age group except 18-20 from 1990-2000; the greatest increase occurred in adults ages 45 and over (Exhibits 1A. 7a-b, 1A.9a-c, 1A.12a-c). The number of Black/African American residents has risen steadily (from 22,223 in 1990 to 27,601 in 2000). In 2007, the Black/African American population was estimated to be 39,852, an increase of over 44% since Census 2000. Most of the increase has occurred in the cities of Newburgh and Middletown and town of Wallkill where the greatest numbers of Blacks/African Americans reside. The Black/African American population increased in every age group except 21-34; the greatest increases occurred in ages 10-17, 35-44, and 85 and over. (Exhibits 1A.7a-b, 1A.9a-c, 1A.13a-c) Nativity and Primary Languages Spoken Since 1990, the ethnic and racial minority population has increased at a substantially higher rate in Orange County than the non-minority population. A proportion of this increase is attributable to the influx of immigrants into the county, many of whom have entered the U.S. in the past decade and have limited English language proficiency (verbal and written). In 2000, 8.4% of Orange County residents were born in other countries compared with 7.2% in 1990. Over nine thousand (9,082) foreign born persons entered Orange County over the past decade, up from 6,964 from 1980 to 1990. The majority (45.2%) were born in Latin America, 34.1% were born in Europe, and 16.4% were born in Asian countries. Mapping by zip code shows that the primary communities where immigrants settled during this time include the cities of Newburgh and Middletown. (Exhibit 1A.14a-b) Orange County Community Health Assessment 2010-2013 Section I 2

The majority of persons who speak English less than very well are found in the cities of Newburgh and Middletown, town of Wallkill, and village of Kiryas Joel. The city of Newburgh has the highest concentration of persons with Spanish as the language spoken at home (8,191persons/32% of the population ages 5 and over) followed by Middletown (4,684 persons/20% of the population ages 5 and over). The concentration of persons speaking Asian/Pacific Island languages at home is much less than for Spanish, and Wallkill has the highest number (370) followed by the town of Newburgh (334). (Exhibit 1A.15) School district data indicates that the highest levels of limited English proficiency in students are found in the school districts serving these same communities. A unique situation is also found in the Yiddish-speaking Hasidic community of Kiryas Joel where nearly 75% (7,791 out of 10,615) of its residents ages 5 and over speak English less than very well, and 33% of students have limited English proficiency. (Exhibit 1A.15, 1A.16a-c) According to Kids Well-Being Indicators Clearinghouse data, the number of Orange County students K-12 with limited English proficiency has increased by 35% since 2000 from 9.3% to 12.6% in 2007; 3 times the rate for the Rest of State (ROS). (www.nyskwic.org) Educational Attainment, Income and Poverty The overall level of educational attainment of Orange County residents increased from 1990 to 2000. Nearly 82% (81.8%) of Orange County residents ages 25 and over were high school graduates in 2000, 30.7% had an associate s degree and 22.5% had a bachelor s degree or higher. (Exhibit 1A.17) When compared with 1990, these rates represent increases of 4.6, 4.1, and 3.0 percentage points respectively. (www.census.gov) Higher income levels and lower poverty rates are closely associated with higher levels of educational attainment. This pattern is consistent in Orange County communities. Residents in the 5 communities with the lowest median incomes (Middletown, Newburgh city, Port Jervis, Kiryas Joel, and Unionville) consistently report lower levels of education compared with residents in the 5 communities with the highest median incomes (Chester, Tuxedo, Woodbury, Monroe village, and Tuxedo Park). The most affluent community in Orange County as measured by median family income in 2000 ($102,056) is the village of Tuxedo Park. Nearly 72% of Tuxedo Park residents ages 25 and over have college degrees; 39.6% have graduate or professional degrees. In contrast, the lowest median family income in 2000 was reported in Kiryas Joel ($15,372), where 18.1% of residents have less than a 9 th grade education compared with the county average of 5.6%. (Exhibits 1A.17, 1A.18) Educational attainment indicators for Orange County youth indicate improvement in educational performance and in the intent to pursue higher education. Based on Kids Well-Being Indicators data, the percent of high school graduates receiving Regents Diplomas in Orange County s public schools increased substantially from 1999/2000 to 2006/2007 (49.9% to 81.6%). This is in large part attributed to the phase-in of Regents only diplomas for high school students statewide. The number of high school graduates intending to enroll in college also increased during this same period, from 81% to 83.7%. The high school drop-out rate decreased slightly during this period from 2.6% to 2.5%, and remains below the state rate of 3.1%. (www.nyskwic.org) In 2006-2007, the percentage of high school graduates receiving Regents Diplomas in Public School Districts ranged from a low of 65% in Newburgh city to a high of 94% in Cornwall. (Exhibit 1A.19) Poverty rates vary greatly throughout the county based on municipality. Poverty rates exceeding 25% for individuals in families with related children under 18 are found in Orange County s three cities (Middletown, Newburgh, and Port Jervis), as well as in the town of Monroe, largely due to the impact of the village of Kiryas Joel, where the poverty rate of 63.9% is more than 4 times the county rate of 14.8%. These same communities consistently exhibit the highest rates of individuals in poverty. Higher rates of poverty in persons 65 years of age are found in these communities as well as in several other communities. (Exhibit 1A.20) Not surprisingly, overall participation rates in financial and medical assistance programs (Family Assistance, Safety Net Assistance, Food Stamps, Medicaid and Family Health Plus) are highest in these four municipalities. (Exhibits 1A.21a-b) Eligibility for free school meals, an indicator of severe economic hardship in families, exceeds 25% in the following school districts Kiryas Joel (88%), Middletown city (67%), Newburgh city, (59%) and Port Jervis (38%). (Exhibit 1A.16a) Comparative data from the NYS Kids Well-Being Indicators Clearinghouse show an increase since 2000 in the percentage of children and youth ages 17 and under in the county living below poverty (12.8 to 15.5 in 2005), receiving food stamps (10.1 to 12.1 in 2007), and receiving free or reduced price school lunch (30.8 to 33.0 in 2006/2007). In contrast, the percentage of children and youth receiving public assistance benefits has decreased from 5.3 in 2000 to 3.0 in 2007. (www.nyskwic.org) Levels of poverty in the county also vary depending on race, ethnicity, and family composition. According to Kids Count Census Data Online, while a total of 15.1% of children under age 18 in Orange County lived below the federal poverty level in 2000, this rate differs based on ethnicity and race. The lowest rates of poverty are seen in Asian children (11.2%), followed by White children (12.5%). Poverty levels increase considerably for children from other racial and ethnic minorities to 23.7% for Hispanic/Latinos, 25% for Native Hawaiian or other Pacific Islanders, 28.3% for Black or African Americans and 38.5% for American Indian or Alaska Natives. Dramatic differences in poverty rates are apparent based on family composition and age of the child. Married couple families have the lowest overall poverty rates (9.7%); the highest rates are seen in single mother families (37.5%). This rate exceeds 50% in single mother families with children under the age of five. Interestingly, the poverty rate of children under 5 in single father families (24.2%) is half of that found in single mother families. Poverty rates decline in single parent families with increasing age of the child, most Orange County Community Health Assessment 2010-2013 Section I 3

likely due to improved wage earning ability once children enter school. (Exhibit 1A.24a-b) C. Employment and Housing Characteristics The average annual unemployment rate in Orange County in 2008 was 5.5% which is comparable to the rest of the state exclusive of New York City and slightly higher than that for the Hudson Valley Region as a whole. Unemployment rates in the county, region, state, and nation increased beginning in the last quarter of 2008 due to the economic recession. In March 2009 the unemployment rate in Orange County had increased to 7.9%; rates for the county s two most populated cities were higher (Newburgh 11.4%, Middletown 9.7%). (www.labor.state.ny.us) One-third of Orange County residents are employed in management and professional services; followed by sales and office services (27.2%); service occupations (16.5%); production, transportation and material moving (12.1%); construction, extraction, and maintenance (10.2%); and lastly farming, fishing, and forestry (0.4%). (Exhibit 1A. 25) Major types of employers in Orange County (500+ employees) include county government; community hospitals; senior housing and health care facilities; BOCES; Orange County Community College; Stewart Air National Guard Base; manufacturing and distribution companies; wholesale grocery and mail distribution; transportation services; auto dealer auctions; cable services; and major retail outlets such as Shop Rite and Home Depot. Agricultural centers which employ seasonal migrant farm workers are located in the communities of Pine Island, Florida, and Goshen. Orange County s proximity to both New York City and the more urbanized Westchester County contribute to both a strong commuter base and ease in migration of workers into the county. The county is traversed by 2 major interstates (I-87 & I-84) with the pending upgrade of State Route 17 to Interstate 86. Stewart International Airport is also located within the county, and the ten-year $500 M expansion of the airport to a major hub for air travel in the metropolitan region presents an opportunity for future economic growth. Housing units within the county increased 11% from 1990 to 2000 to 122,754 (114,788 occupied units). In 2007, the estimated number of housing units was 134,047. (www.factfinder.census.gov) The average household size in 2000 was 2.9. (Exhibit 1A.2a) The majority of housing units in the county are owner occupied 67%, however this also varies by municipality. The majority of housing units are renter occupied in the following communities Highlands (West Point), Middletown, Newburgh (city), and Port Jervis. Overcrowding (>1 person per room) is most prevalent in renter-occupied housing in Middletown, Newburgh (city), and Monroe (Kiryas Joel). The number of cost-burdened renters (> 30% of gross income spent on rent) is greatest in Middletown, Monroe (Kiryas Joel), Newburgh and Wallkill, communities previously identified to have low income, high minority populations. Pre-1950 s housing is an indicator of lead poisoning risk. Communities with 50% or more of their housing units consisting of pre-1950 construction include Cornwall, Highlands, Middletown, Newburgh (city), and Port Jervis. Over 70% of the housing units in Newburgh (city) were built prior to 1950; this approaches 80% in Port Jervis. (Exhibits 1A.26a-d) Statistics on homelessness provided by the County Department of Social Services show that in 2008, an average of 156 homeless cases/households were housed per month either in emergency housing shelters, temporary housing in hotel/motels or transitional housing. This is more than double the number of cases/families housed per month in 2006. The number of homeless applicants/cases increased by nearly 40% from 2007 to 2008, and in 2008 1,733 homeless persons received emergency housing assistance. D. Projected Demographic Changes Using an annual growth rate of 1.24%, the Orange County Department of Planning projects the county s population to reach about 465,000 persons by 2025. The 5 communities with the highest projected rates of growth include Monroe (town and villages, including Kiryas Joel), Greenwood Lake, Harriman, and Washingtonville. The communities with the lowest growth rate estimates include the cities of Newburgh and Port Jervis, and villages of Highland Falls, Otisville, and Tuxedo Park. Population estimates from the Cornell Institute for Social and Economic Research (CISER) project the county population reaching 500,000 by 2035. In terms of net population change from Census 2000 to 2020, continued growth is estimated in all age categories for both genders - the one exception is a slight decline in males ages 40-44. The number of residents ages 65-69 is forecasted to more than double from 2000 to 2020 primarily due to the entry of baby boomers into these age ranges. (Exhibits 1A.27, 1A.28) The age structure and the racial and ethnic composition of the population are anticipated to continue to change. The number of persons ages 65 and above is projected to continue to increase. Since older persons tend to require more health care services than younger persons, increasing demands on health care resources are anticipated in the upcoming decades. In addition, the relative proportion of racial and ethnic minorities is expected to continue to increase compared with nonminorities. Sustained increases in the number of immigrants are also projected to continue, which impacts both the need for culturally and linguistically appropriate health care services and the availability of preventive, primary, and specialty health care services for the uninsured and working poor. E. Regional Perspective Among the seven counties in the Hudson Valley Region (HVR), Orange County is the second most populated county; Westchester County ranks first. In terms of population density, Orange County ranks third of the seven counties in our region, closely followed by Putnam County. The rate of population growth in Orange County over the past 7 years is estimated to exceed that of all other counties in the state. Based on Orange County Community Health Assessment 2010-2013 Section I 4

Census 2000, Orange County ranks second in Hispanic/Latino population (11.6%) in the HVR; the highest percentage is found in Westchester (15.6%). The Black/African American population in Orange County (8.1%) ranks 5 th among the 7 counties in the HVR. The age distribution of Orange County residents is similar to the other counties in our region; however, Orange County ranks first for the percentage of persons in the youngest age interval (0-19), and second to last for the percentage of persons 65 and over. (Exhibit 1A. 30) In terms of income and educational attainment, in 2000, Orange County families rank 5 th out of the 7 counties in median family income ($ 60,355) and 6 th in the percentage of residents with a college or graduate degree (30.7%). Putnam County leads the Hudson Valley Region in family income and Westchester leads the region in the level of educational attainment. (Exhibit 1A. 30) SECTION ONE: POPULATIONS AT RISK A. DEMOGRAPHIC AND HEALTH STATUS INFORMATION 2. Causes of Mortality in Orange County A. Overall Mortality Mortality data are some of the most available and reliable indicators of health status in a community. Mortality data are highly useful in providing insight about current health problems, identifying the underlying risk factors for disease, and analyzing trends in the leading causes of death over time. As discussed in detail in Section 1C Behavioral Risk Factors, many of the leading causes of death in the U.S., NYS, and in Orange County are closely associated with external risk factors that are in large part preventable or controllable. Risk factors that can be modified include environmental factors and personal behaviors. The leading causes of death in the United States are closely linked to personal behaviors, injury, violence, environmental factors, and the unavailability or inaccessibility of quality preventive, primary, and specialty health care services. In the following narrative, mortality is discussed primarily in the context of age- and sex-adjusted rates in the population, consistent with standard practice in chronic disease epidemiology. By adjusting to a standardized age-sex distribution, these standardized rates eliminate the effects of age and gender composition on the reported rates of illness in the populations under study. In other words, when the risk of illness, such as cerebrovascular disease, increases with age, a population with higher proportions of people over the age of 50 will almost certainly exhibit higher crude (i.e., unadjusted) rates than a younger population - but for epidemiologically unimportant reasons. Since many causes of mortality typically vary predictably across age groups and genders, it is important in comparing rates to eliminate these confounding factors. Note that age-adjustment is recommended whenever the risk of mortality varies systematically with age - not only when the rate increases. Thus, mortality from motor vehicle accidents, which is elevated in younger (and male) adults, also must be age- and sex- adjusted. Age-sex adjusted rates permit comparison of mortality rates across populations, so long as they are standardized to the same reference population. In this report, mortality rates are age-sex adjusted to the 2000 U.S. Census standard population. It should be noted that age-sex adjusted rates should not be used to compare the absolute magnitude of mortality in a population; for this purpose, the crude mortality rate should be used. Mortality rates by cause occurring in 2000 and later were coded by the New York State Department of Health (NYSDOH) using version 10 of the International Classification of Diseases (ICD-10). Rates based on the ICD-9 codes (1999 and previous years) are not directly comparable with those from 2000 and later. Mortality rates are expressed based on the number of deaths per 100,000 population for the specified cause and demographic or geographic subgroup. To assess health status within in the county, health indicators were also calculated for demographic and geographic subgroups (e.g., age, race, ethnicity, and geographic zones). The Prevention Research Center at the University at Albany School of Public Health in collaboration with OCDOH compiled birth and mortality data sets based on selected demographic and geographic factors. Unfortunately, births and deaths of Orange County residents that occurred and, therefore, were registered in New York City were not available for inclusion in the calculation of county rates. Analyses were performed validating that the impact of this noninclusion on the county results was insignificant. Due to the small population sizes, within-county rates were generally not tested for statistical significance. Differences in the observed rates by subgroups are therefore discussed in relative terms of apparent differences, and do not imply statistical significance. When observed differences were found to be significant, (as approximated by non-overlapping of 95% confidence intervals), this is so noted in the narrative for that indicator. The time period covered in this report spans a period of rapidly evolving standard practices in reporting raceethnicity data, driven in part by changes in US Census Bureau policies. Data reported in this document reflect the current practices for the time period by the reporting agency, usually NYSDOH. Given the complexity, the reader is referred to the following web page for a complete explanation of these practices: http://www.health.state.ny.us/nysdoh/vital_statistics/2 007/technote.htm Orange County Community Health Assessment 2010-2013 Section I 5

Mortality trends are reviewed in terms of 3-year averages to stabilize single year rates, and permit a more robust comparison with rates for the Hudson Valley Region and Upstate (also referred to as Rest of State meaning NYS excluding NYC). Whenever possible, mortality trends are described within and among major subgroups in Orange County: males and females, and racial and ethnic subpopulations (White, Black/African American, and Hispanic/Latino; Asian race was not able to be included in the within county analysis due to the relatively small numbers). With this information, we are able to better assess progress towards eliminating health disparities among these subpopulations. Mortality rates are also compared with Healthy People 2010 (HP 2010) and Prevention Agenda (PA 2013) targets. For over two decades, Healthy People objectives have provided a framework for evaluating the health status of populations with a focus on disease prevention and health promotion. The overarching goals of Healthy People 2010 and the NYS Prevention Agenda are to increase quality years of healthy life and to eliminate health disparities. In the U.S., NYS, and Orange County, the major causes of death and disability include chronic diseases such as heart disease, cerebrovascular disease (stroke), malignant neoplasms (cancer), diabetes, and accidents in younger age groups. Using the national benchmarks in HP2010 and PA2013 state benchmarks assist in monitoring improvements in health status of county residents and in targeting particular health issues for further study and community action. As shown in Exhibit 1A. 33a-c, for the 3-year period from 2004-2006, the age-sex adjusted mortality rate from all causes of death in Orange County was 734.6 (per 100,000 population). Since 1998-2000, there has been a steady decline in the 3-year average age-sex adjusted mortality rate in the county. The 2004-2006 age-sex adjusted mortality rate (3-year average) for county residents was below the Upstate rate. Analysis of age-sex adjusted death rates for selected causes of death yield the following trends when comparing Orange County data with ROS and NYS. In 2005-2007, age-sex adjusted death rates for county residents were consistently above those for ROS for the following causes of death: cerebrovascular disease, pneumonia, CLRD, and cirrhosis. County age-sex adjusted death rates were consistently below those for ROS for homicide and legal intervention. In comparing within county rates from 2005-2007, consistent improvement in age-sex adjusted death rates are reported for cerebrovascular disease, AIDS, pneumonia, and diabetes mellitus. (www.health.state.ny.us/nysdoh/ vital_statistics) B. Mortality Rates of Different Demographic Subpopulations Gender is a known determinant of health status, life expectancy, and risk of death. In most industrialized nations, females have lower age-adjusted mortality rates from all causes compared with males. Although these differences are in part biological, there are also social determinants such as willingness to seek preventive care and comply with treatment regimens, risk-taking behaviors, and patterns of alcohol, drug use, and interpersonal violence that may contribute to mortality rates. In Orange County, the age-adjusted overall mortality rate for males exceeds that for females, which is consistent with findings for the HVR and Upstate. In absolute numbers, there were more deaths in female than male residents in the county from 2004-2006, owing to the predominance of females in older age groups (which have the highest mortality rates). Differences in mortality rates by race and ethnicity are inextricably linked to a variety of socioeconomic factors that are not easily disaggregated. For the 3-year period of 2004-2006, the mortality rate for Black/African Americans in the county is highest, followed by that for Whites. Hispanic/Latinos have the lowest overall mortality rate in the county, which is consistent with findings in NYS. This lower rate should be interpreted with caution as a possible explanation is that Hispanic/Latino ethnicity may be underreported on death certificates. Geographically, mortality rates are also interconnected with a host of socioeconomic factors (e.g., income, poverty, educational level, housing/neighborhood safety). Overall mortality rates are highest in the county s 3 cities of Middletown, Newburgh, and Port Jervis, and the rates were statistically higher than the county and zone rates. (Exhibit 1A. 33a-c) Rank Order C. Leading Causes of Death Figure 1 - TOP 10 LEADING CAUSES OF DEATH IN ORANGE COUNTY NY, 2005-2007 Cause of Death Number of Deaths Percent of Total Deaths (all causes) n=7,337 1 Diseases of the Heart 2,065 28.1 2 Malignant Neoplasms 1,824 24.9 3 Chronic Lower Respiratory Disease (CLRD) 443 6.0 4 Cerebrovascular Disease 343 4.7 5 Total Accidents 294 4.0 6 Pneumonia 232 3.2 7 Diabetes Mellitus 181 2.5 8 Cirrhosis of the Liver 83 1.1 9 AIDS 31 0.4 10 Homicide and Legal Intervention 23 0.3 As shown in Figure 1, heart disease and cancer combined accounted more than half (53%) of all county resident deaths in 2005-2007. From 2004-2006, the top 5 leading causes of death in Orange County by rank order were: 1) diseases of the heart, 2) malignant neoplasms, 3) CLRD, 4) cerebrovascular disease and 5) total accidents. (Exhibit 1A.34) The rank order of the top 5 causes of death in Orange County remained constant compared with 2000-2002. The top five Orange County Community Health Assessment 2010-2013 Section I 6

causes of death in the rest of NYS in 2004-2006 were: 1) diseases of the heart, 2) malignant neoplasms, 3) CLRD, 4) cerebrovascular disease, and 5) total accidents. Trends in mortality rates by cause are discussed in the narrative sections for chronic and communicable diseases. The leading causes of death in Orange County, as in NYS and the U.S., vary depending upon age and gender. Exhibit 1A.35 compares the leading causes of death and mortality rates by these factors. The leading cause of death in younger children (<10 years of age) is accidents. For ages 10-24, the main causes of death are 1) accidents followed by 2) suicide and 3) diseases of the heart. For adults ages 25-44, the top three causes are 1) accidents, 2) malignant neoplasms, and 3) diseases of the heart; for adults ages 45-54 the leading causes are 1) malignant neoplasms, 2) diseases of the heart, and 3) accidents; for ages 55-64 these are 1) malignant neoplasms, 2) diseases of the heart, and 3) diabetes; for ages 65-74 leading causes include 1) malignant neoplasms, 2) diseases of the heart and 3) COPD/CLRD; for ages 75-84 leading causes include 1) diseases of the heart, 2) malignant neoplasms, and 3) COPD/CLRD; and for adults ages 85 and over 1) diseases of the heart, 2) malignant neoplasms, and 3) cerebrovascular disease are the leading causes of death. SECTION ONE: POPULATIONS AT RISK A. DEMOGRAPHIC AND HEALTH STATUS INFORMATION 3. Health Status of County Residents Certain health events occur infrequently or involve confidentiality issues such as induced terminations of pregnancy and HIV/AIDS. Furthermore, reporting small numbers of health events in a county or municipality produces unreliable rates. Vital statistics and other health data are especially unstable if based on fewer than 20 events. This is because small changes in the number of events or cases will cause dramatic shifts in rates; this is sometimes referred to as small numbers phenomenon. Displaying health indicators that are based on very small numbers of events may also jeopardize confidentiality. (Healthy People 2010 General Data Issues) For these reasons in the presentation of certain health indicators, data may not be included in some Exhibits, or only be displayed at the county level from NYSDOH to assure that confidentiality is maintained. When data are not included in an Exhibit due to the small number of events or cases, this is indicated in the Exhibit by the code s/n. For mortality rates, in most instances, we have adopted the NYSDOH Cancer Registry practice of suppressing numbers (and resultant rates) where the number of deaths is below 20. In analysis of birth indicators, numbers from 1 through 5 are suppressed to protect confidentiality. A. Family Health 1. Child and Adolescent Health Introduction This section addresses the health status and primary and preventive health care of children and adolescents residing in Orange County. Preventive health care is important to persons of all ages, but is especially important for infants, children, and adolescents to avoid preventable illness and to lay the foundation for good habits that promote and maintain health throughout life. Preventive health care for children begins in the pre-conceptual period, and continues through the stages of fetal growth and development. After birth it includes periodic health screenings and examinations, assessment of growth and development, vaccination for preventable childhood diseases, and anticipatory health guidance and education on such health issues as nutrition, oral health, injury prevention, and the importance of regular physical activity. As described in Section II: Local Health Unit Capacity Profile, OCDOH programs, services and community collaborations are targeted to improvements in individual, family, and community health, and in assuring the safety of the environment in which county residents live. Populations at Risk As of the 2000 Census, there were 108,869 children and adolescents ages 19 and under residing in Orange County; in 2007 this is estimated to have increased by about 4% to 113,313. In general, the health of Orange County children is relatively good; however, there are vulnerable groups within the population who lack consistent access to primary and preventive health care. A primary risk group is children living in families without adequate health insurance coverage. Uninsured children may receive episodic treatment for acute medical problems, but often do not have consistent access to preventive health care. Children may be uninsured due to family income exceeding limits for public insurance programs like MMC/Child Health Plus, or because they are undocumented immigrants who fear enrollment in any government-run programs, regardless of whether or not they are eligible. Disparities in income, discussed in the previous Section 1A.1B Demographics, show that children under the age of 5 living in female-headed households are at highest risk for living in poverty in the county. Even with health care coverage through MMC/Child Health Plus, the complexity of everyday life for many families living in poverty precludes preventive health care being a priority. Children living in homes with complex psychosocial problems such as substance abuse, domestic violence, and child abuse are also at risk for lack of consistent preventive health care. Another indicator of lack of access to preventive health care in children is the rate of Ambulatory Care Sensitive (ACS) conditions (asthma, otitis media, gastroenteritis and pneumonia) reported as diagnoses in hospital Orange County Community Health Assessment 2010-2013 Section I 7

discharge records. Since the vast majority of ACS conditions can be treated successfully in an ambulatory care setting, a high rate of ACS-related hospitalizations suggests barriers to accessing primary care to prevent these conditions from becoming serious enough to require hospitalization. They also may reflect a higher disease incidence in an area. Data for the 3-year period (2000-2002) for Orange County s youngest children (ages 0-4) reported that the hospitalization rates for asthma, otitis media, gastroenteritis and pneumonia were higher than the HVR and the average for Upstate. Analysis of the most recent comparative data (2004-2006) shows improvement in hospitalization rates for county residents within this age group for asthma, pneumonia, and otitis media. Improvements in hospitalization rates for otitis media are dramatic, and in 2004-2006 were below those of NYS, Upstate, and the HVR. Three-year hospitalization rates for Orange County infants and children ages 0-4 remain consistently above those for the HVR for the other ACS conditions. Ten year time trends (1997-2006) show hospitalization rates in the 0-4 population are consistently above those for Upstate for all ACS conditions except otitis media. When compared with hospitalization rates for NYS (including NYC), Orange County rates remain higher for 2 of the 4 ACS conditions - gastroenteritis and pneumonia. When looking at hospitalization rates for asthma in Orange County s 5-14 year olds, the rate becomes much lower than the rate for NYS, but remains well above the average for the HVR and Upstate. (Exhibit 1A.36 a-e). Chronically Ill Children and Children with Disabilities According to the 2000 Census, 6% of children ages 5-15 in the county are disabled. Of the 3,967 disabled children in this age range, the majority have mental disabilities. The October 2006 Orange County Community Profiles Needs Assessment, a collaborative effort of the Orange County Youth Bureau; Department of Social Services; and Partners for Children, Youth, and Families; reports the Orange County public school districts with the highest 3-year average enrollment of students with disabilities include: Tuxedo (15.3%), Pine Bush (14.6%), Monroe-Woodbury (13.8%) and Chester (12.9%). (www.orangecountygov.com) As described in Section II Local Health Unit Capacity Profile, 3,856 preschool children with disabilities or at risk for developmental delay were receiving services through the OCDOH Early Intervention and Preschool Special Education Programs in 2007-2008, an increase of over 20% in 5 years. Child Abuse and Maltreatment According to New York State Law (NYS Family Court Act, Section 1012 e) an Abused Child is a child less than eighteen years of age whose parent or other person legally responsible for his care inflicts or allows to be inflicted upon the child serious physical injury, or creates or allows to be created a substantial risk of physical injury, or commits or allows to be committed against the child a sexual offense as defined in the New York State Penal Law. A Maltreated Child (NYS Family Court Act, Section 1012 f) is a child under eighteen years of age who has had serious physical injury inflicted upon him by other than accidental means, whose physical, mental or emotional condition has been impaired or is in danger of becoming impaired as a result of the failure of his parent or other person legally responsible for his care to exercise a minimum degree of care in supplying the child with adequate food, clothing, shelter, education, medical or surgical care, though financially able to do so or offered financial or other reasonable means to do so; or in providing the child with proper supervision or guardianship; or by unreasonable inflicting, or allowing to be inflicted, harm or a substantial risk thereof, including the infliction of excessive corporal punishment; or by using drug or drugs; or by using alcoholic beverages to the extent that he loses selfcontrol of this actions; or by any other acts of a similarly serious nature requiring the aid of the Family Court. The Orange County Department of Social Services (OCDSS) reports the following data regarding Child Protective Services (CPS) Reports for Child Abuse and Maltreatment in Orange County for 2005-2008: Reporting Year 2005 2006 2007 2008 No. of Reports 2,819 3,167 3,473 3,452 Filed/Investigations According to Kids Well-Being Indicators Clearinghouse data, 25.7% of child abuse and maltreatment reports filed in 2005-2007 in Orange County were indicated, which is below the percentages for NYS and ROS. Lead Poisoning Prevention Children younger than six years of age are at highest risk for childhood lead poisoning, and are most susceptible to its damaging effects. The nervous systems of young children are still developing and if exposed to lead, young children are more likely to ingest it and it is more readily absorbed from their gastrointestinal tracts. Prompt screening and treatment are effective in eliminating deaths and severe disability from exposure to high levels of lead (lead encephalopathy); however even at low levels of exposure lead can slow growth in children, affect hearing, cause anemia, and damage to kidneys and the nervous system. Children living in low income areas have historically been at highest risk for lead poisoning, due in large part to the fact that they are more apt to live in older, deteriorating housing with lead paint hazards and also have poorer nutrition (good nutrition protects against lead absorption) and less access to primary and preventive health care. However, children living in moderate and higher income families are also at risk for lead poisoning because of exposure to leaded paint in older, vintage homes especially if these homes are occupied while being renovated. (www.health.state.ny.us/environmental/lead) NYS Public Health regulations require that all health care providers screen one and two year olds for elevated blood lead levels (universal screening). In addition, pediatric health care providers must assess all children under the age of six for risk of high dose exposure to lead and provide lead screening if at risk. Orange County Community Health Assessment 2010-2013 Section I 8

OCDOH s Childhood Lead Poisoning Prevention Program (CLPPP) works in partnership with NYSDOH and local health care providers to promote universal screening, and coordinate efforts to prevent, detect, and treat lead poisoning in the community. These services, discussed in detail in Section II Local Health Unit Capacity Profile, include: Educating the public and health care providers about prevention, early detection, and appropriate treatment of childhood lead poisoning; Providing case management for children with elevated blood lead levels (EBLLs), including environmental inspection and assessment of the child s environment; Collecting and analyzing data on the extent and severity of lead poisoning and EBLLs in Orange County communities. The most recent comparative data for lead screening rates and the incidence of EBLLs for Orange County and other NYS counties available from NYSDOH are the 2002 birth cohort data (2003-2005 blood lead testing) cited in Eliminating Lead Poisoning in New York State: 2004-2005 Surveillance Report. (www. health.state.ny.us/environmental/lead) The average percentage of children screened by age 2 in Orange County was in the highest quartile (>49.7%) for NYS exclusive of NYC, which is a substantial improvement compared with the 1995-1997 birth cohort. The percentage of Orange County children screened between ages 9 months and less than 18 months was 54%; between ages 18 months and less than 36 months the percentage was 52.1%. These percentages exceed those for the state overall (53.1% and 45.2% respectively). When compared with other HVR counties, Orange County's ranking for screening rates by age interval is 5 th among the seven HVR counties for 9 months to less than 18 months and 4 th for 18 months to less than 36 months. The percentage of Orange County children receiving two screening tests by 36 months of age was 31.2% compared with 33.1% statewide; Orange County ranked 5 th among the seven HVR counties for this indicator. The three-year average incidence rate in children less than 6 years of age with a confirmed BLL of >10 micrograms per deciliter (ug/dl) per 1,000 children in the county tested was 20.4. This is well above the state average incidence rate (13.3/1,000), and that for other HVR counties. Orange County ranked 15 th out of the 57 Upstate counties for this indicator. County incidence rates were consistently higher that the state and other HVR counties across all categories of EBLLs: 10-14 ug/dl, 15-19 ug/dl, and 20 ug/dl and over. (Exhibits IA.37, IA.38) The HP2010 target for EBLLs is 0% for children ages 1-5 with BLL of >10 ug/dl. These findings demonstrate the need for continued vigilance to achieve universal testing at age 1 and 2 by pediatric providers and for ongoing lead poisoning primary prevention and risk reduction efforts. NYSDOH identifies high incidence (top decile) zip codes throughout NYS for BLLs > 10 ug/dl. The two zip codes so designated in the county in 2005 were 12550, the city of Newburgh and 10940, the city of Middletown. The Newburgh zip code had the highest number of newly identified children with EBLLs of any zip code in the state, exclusive of NYC. In 2007, New York State funded a $3M primary prevention pilot program for counties with high incidence zip codes to identify housing at greatest risk of lead-paint hazards, develop partnerships and engage communities to promote primary prevention of childhood lead poisoning, promote interventions to create lead-safe housing units, build lead-safe work practice workforce capacity, and identify community resources for lead hazard control. Please refer to Section II Local Health Unit Capacity - Community Health Outreach for additional program information. There were a total of 29,898 children tested for lead from 2005-2008. Of that number, 182 (0.6% of those tested) children had a BLL of 20 ug/dl, 149 of these children (81.9%) were ages 36 months and younger. There were a total of 549 children with a BLL between 10-19 ug/dl (1.8% of those tested), 447 of these children (81.4%) were ages 36 months and younger. Immunization As of January 1, 2008, the NYS Immunization Registry Law requires health care providers to report all immunizations administered to persons less than 19 years of age, along with the person's immunization histories, to NYSDOH using the recently launched statewide web-based immunization information system (IIS). Once fully implemented, the New York State Immunization Information System (NYSIIS) will be the official source of NYS immunization information. The goal of the system is to establish a complete, accurate, secure, real-time immunization medical record that is easily accessible and promotes public health by fully immunizing all individuals appropriate to age and risk. An IIS provides numerous benefits to all those involved in the health care of children, contributing to a higher immunization rate and a healthier population. At present, countywide data on childhood immunization coverage levels are unavailable; aggregate data for coverage levels in children ages 2 and younger receiving care in health provider sites surveyed through the county s Immunization Action Plan (IAP) follows. OCDOH IAP works with health care providers in the county to promote and achieve full immunization coverage in children by two years of age. The Division of Public Health Nursing conducts immunization clinics at multiple sites to provide childhood immunization to families with difficulty accessing these services in the community due to financial barriers. In addition, IAP staff conduct medical provider visits to review a representative sample of records and assess immunization coverage levels of one and two year olds in their practices (Provider-Based Immunization Initiative or PBII). A computer generated report is used by IAP staff to provide feedback to providers and specific information on how to improve immunization coverage levels in their practices. PBII assessments are conducted annually in Community Health Centers (CHCs), OCDOH Immunization Clinics, and private Orange County Community Health Assessment 2010-2013 Section I 9

pediatrician practices. The aggregate coverage level for 4:3:1:3:3 (4 DTaP, 3 Polio, 1 MMR, 3 Hib, 3 Hepatitis B) for health care providers assessed through PBII in 2006 was 84%, above the NYS level (Figure 2). The coverage level for 4:3:1 (4DTaP, 3 Polio, 1 MMR) in 2006 was 86%. PBII coverage levels dropped in 2007 for the practice sites surveyed and coverage rates in 2008 were identical to those for 2006. Figure 2 Source: NYSDOH, Community Health Data Set 2006 Nutritional Status Although not representative of the general pediatric population in the county, the NYSDOH Pediatric Nutrition Surveillance System (PNSS) collects data on the prevalence of overweight and underweight in low income infants and children enrolled in the Women, Infants, and Children Supplemental Food Program (WIC Program). The PNSS defines underweight as less than 5th percentile based on the 2000 CDC growth chart percentiles for weight-for-length for children under 2 years and a body mass index (BMI)-for-age for children 2 years and older. Overweight is defined as more than or equal to the 95th percentile based on the 2000 CDC growth chart percentiles for BMI-for-age. Rates of overweight and underweight in WIC participants (who are low income) ages 0-4 tested in Orange County in 2004-2006 were 6.3% for underweight and 13.9% for overweight. The rate for underweight ranks second in the HVR; for overweight Orange County ranks sixth out of the 7 counties in the region. Statewide rates were 4.8% for underweight and 15.2% for overweight. The prevalence of obesity in children and adolescents has increased dramatically in the U.S. Overweight and obesity acquired during childhood or adolescence may persist into adulthood and increase the risk for certain chronic diseases later in life. The Healthy People 2010 target is to reduce the prevalence of overweight and obesity among children and adolescents to no more than 5 percent using gender- and age-specific 95th percentile of BMI from the current CDC Growth Charts. The reduction of BMI in children and adolescents should be achieved by emphasizing physical activity and a properly balanced diet so that healthy growth is maintained. Additional research is needed to better define the prevalence and health consequences of overweight and obesity in children and adolescents and the health implications in adulthood. A recent study conducted by the Karolinska Institute in Sweden provided support for the link between late adolescent overweight and obesity and risk of premature death. (Neovius et al, BMJ, 2009 @ http://ki.se/ki/jsp) In 2007-2008, NYSDOH initiated a pilot project in response to 2007 NYS legislative mandates to collect and report student weight status and BMI. For the 2008-2009 school year there is a mandatory 50% sample of school districts for all Upstate counties. The remaining 50% will be required to report in 2009-2010. All public schools within identified school districts are required to report aggregated information from school health certificates/appraisals for students in prekindergarten or for kindergarten and in grades 2, 4, 7 and 10. These data, once available will provide insight into the prevalence of childhood and adolescent obesity in Orange County and comparative data to other Upstate counties. The percentage of children ages 6 months to 4 years enrolled in the WIC Program in Orange County who were classified as anemic based on screening tests from 2004-2006 was 11.2%. This percentage was identical to that for the HVR and comparable to the percentage for NYS (11.5%). This is well above the HP2010 target of 5% for 1 to 2 year olds and 1% for 2 to 4 year olds; however this is not representative data as WIC participants are low income. One cause of anemia in infants and children is iron deficiency. Iron deficiency occurs most frequently in toddlers and among certain racial and ethnic groups and low income children. (www.health.state.ny.us/nysdoh/chac/chds. htm; www.healthypeople.gov) Dental Health Nearly 80% of NYS children have experienced dental decay (a preventable disease) by the end of high school. (NYSDOH Oral Health Survey, 2003) Surveys have shown that low income children are at increased risk for oral health problems. Lack of affordable dental care is a major barrier to the receipt of timely and periodic preventive care by children. In 2003, NYSDOH conducted a representative survey of the oral health status of 3 rd grade children. The survey included a selfadministered questionnaire completed by a parent/guardian and an oral screening by a licensed dentist or hygienist. The results for Orange County showed that 55.7% of third graders had experienced caries (HP 2010 target - 42%), over one-third (36%) had untreated caries (HP 2010 target 21%) and 31.8% had sealants (HP 2010 target 50%). Only 70% indicated they had visited the dentist in the past 12 months (HP 2010 target 56%; PA 2013 target 83%), and this coupled with the untreated caries rate is suggestive of a lack of access to or utilization of preventive oral health services by this age group of children. Adolescent Health Risks The majority of adolescents in Orange County enjoy favorable health. Certain health events, although rare or infrequent in adolescents in the county, are nonetheless important to monitor over time to assess Orange County Community Health Assessment 2010-2013 Section I 10

adolescent physical and psychosocial well-being and to identify health risks that are amenable to prevention efforts. Such health status indicators for adolescents in Orange County include: Leading Causes of Death: Overall mortality rates in adolescence are low compared to those in young adulthood. Nonetheless, the majority of these deaths are due to unintentional injury, and are preventable. From 2004-2006 there were 50 deaths to adolescents ages 15-19 in Orange County. The leading cause of death for adolescents in the county is accidents, and the most common type are motor vehicle accidents. Alcohol plays a major role in motor vehicle accidents in all ages, including underage drinkers. According to NYS Kids Well-Being Indicators, the rate of young adult (ages 16-21) arrests for Driving While Intoxicated (DWI) in the county has consistently exceeded the rate for the ROS from 2003-2007 (Exhibit 1A.39a) In adolescents, the majority of deaths are in males, which is in large part attributed to risk-taking behaviors. (Exhibit 1A.35) The death rate for 2004-2006 in children and adolescents ages 5-14 in the county (12.3/100,000) was higher than that for the HVR. This rate did meet the HP2010 target for ages 5-9 but not for ages 10-14. The death rate for adolescents ages 15-19 in the county (56.7/100,000) exceeded the HP2010 target of 38/100,000, and the average for the HVR and NYS for 2004-2006. (Exhibit 1A.40) Teen Suicides and Self-Inflicted Injuries: Due to the small number of events, teen suicide rates tend to be highly variable, and should be interpreted with caution. From 2004-2006 there were a total of 5 deaths due to suicide in Orange County adolescents ages 15-19, and the 3-year adjusted average suicide rate was 6.1/100,000 compared with 5.3/100,000 for the HVR. The hospitalization rate for self-inflicted injuries in Orange County adolescents ages 15-19 during this same time was essentially the same as that for the HVR and slightly above the rate for NYS. (Exhibit 1A.41) Substance Abuse: The NYS Office of Alcoholism and Substance Abuse Services (OASAS) 2005 Risk Profile for Orange County (www.oasas.state.ny.us) documents the following trends in rates for alcohol and other drug use by county youth for the most recent time period available, 1994-2002. It should be noted that these rates may be influenced by factors such as the intensity of surveillance and enforcement activities, and the number of repeat offenders within the population. Youth OASAS Alcohol Treatment rates in the county remained lower than those for NYS for all years with the exception of 2001. Youth OASAS Drug Treatment rates remained above the NYS average since 1994. The county rate of youth drug arrests remained well above the NYS average for 1994-2002. Rates for youth drug-related hospital diagnoses in the county have decreased since 2000, and were below the state average from 2001-2002. Youth Probation Case rates for drug use and alcohol use at offense and court mandates for drug and alcohol use have remained consistently higher than the NYS average since 1994. More recent data from the NYS Kids Well-Being Clearinghouse comparing Orange County with the Rest of State show a reduction in the rate of young adult (ages 16-21) arrests for drug use, possession, and sale from 2005-2007, however Orange County s rate remains above that for ROS. DWI arrest rates for Orange County young adults have increased since 2005, which may be attributed in part to enhanced surveillance and enforcement efforts. (Exhibit 1A.39a) Adolescent Pregnancies and Births Teenage pregnancy is an important health and social issue for a number of reasons. Adolescents are more likely to have unplanned pregnancies and to become single parents. This poses significant economic and psychosocial stresses on teen mothers and parents, including being less likely to complete their education, find adequate employment, and achieve a stable home environment. Teen mothers, especially young teenage mothers, are at greater risk for having low birthweight infants. Pregnancy rates in a given population are based on live births, induced terminations of pregnancy (ITOPS or abortions), and spontaneous terminations of pregnancy (STOPS or miscarriages) per 1,000 females in a specified age range. Birth rates include all live births per 1,000 females of the specified age. Pregnancy rates in teens ages 15-19 have generally declined both in Orange County and Upstate NY over the ten-year period of 1997-2006. Pregnancy rates for Orange County teens ages 15-19 have been consistently above the rates for Upstate since 1997; pregnancy rates for teens 10-14 have varied and remained close to Upstate rates. From 2004-2006, Orange County pregnancy rates for teens ages 10-14 were slightly above that for the HVR and below NYS rates. For teens ages 15-17 and 15-19, Orange County rates were higher than the HVR and below those for NYS. The pregnancy rate for females ages 15-17 of 25.6/1,000 met the HP2010 target of no more than 43/1,000 females ages 15-17. (Exhibit 1A.42a-c) During 1997-2006, birth rates in teens ages 15-19 in Orange County have also shown a declining trend and the birth rate for females ages 10-14 has declined since 2004. The birth rate for Orange County females ages 15-17 and 15-19 declined from 2005-2006. The birth rate for Orange County females ages 15-19 fell below the rate for Upstate for the first time in 2006. The birth rate for teens ages 10-14 has fluctuated around that for Upstate over the ten-year time period, and fell slightly below the rate for Upstate in 2006. In 2004-2006, Orange County birth rates for teens 15-19 were slightly above the average for HVR counties and below the average for NYS; rates for teens 10-14 were above the average for Upstate and below to the average for NYS. County rates are unstable however as they are based only 13 births. There has also been a consistent decline in the teenage birth rate percentage per 100 live births in the county since 1997; in 2004-2006 this Orange County Community Health Assessment 2010-2013 Section I 11

rate remained above that for the HVR and below the overall state rate. (Exhibit 1A.44a-c, 1A.45) Analysis of births to females ages 17 and under within the county from 1998-2006 shows the following by race/ethnicity and geographic zones in the county: in absolute numbers, teen births are highest in White teens, followed by Hispanic/Latina and Black/African American teens; as a percentage of total births in each racial/ethnic group the highest percentage are in Black/African American teens, followed by Hispanic/Latina and White teens. Births to teens are most common (as a percentage of total births by zone) in the county s three cities of Middletown, Newburgh and Port Jervis, and the rates were significantly higher than the county average (CI 95%) (Exhibit 1A. 46a-c) The economic, psychosocial and health correlates of teen pregnancies are supported by findings for teens in Orange County. The rates of Medicaid/Self Pay births are highest in females ages 10-24. (Exhibit 1A.47a-d) Pregnant teens in Orange County are also less likely to have early prenatal care (during the first trimester), and are more likely to have delayed or no prenatal care, a known risk factor for poor birth outcome. (Exhibits 1A.48a-d, 1A.49a-e) County teens also have higher rates of births with short gestation (< 37 weeks) or preterm births, and low birthweight (<2500 grams) when compared with women ages 20-44. Rates of births with short gestation and low birthweight are also higher in women ages 45 and over. (Exhibits 1A.50a-e, 1A.51a-e) The Maternal Infant Service Network (MISN) serves Orange, Sullivan, and Ulster Counties. Its mission is to ensure that every woman of childbearing age and her family have access to a full range of preventive and primary health care, social, nutritional, and educational services needed for healthy pregnancies and babies. According to data from the MISN, the Induced Termination of Pregnancy (ITOPS) rate in Orange County is lower than that in Sullivan and Ulster Counties; the percentage of live births to total pregnancies is significantly higher in Orange, Ulster, and Sullivan Counties than the New York State average. Rates for ITOPS or abortions are typically highest in teens. MISN data report the rate of induced abortions in the county overall was 21%; for teens ages 15-19 it was more than double this rate. (www.misn-ny.org) Prevention efforts that reduce the number of unwanted and unplanned pregnancies in teens would significantly reduce overall ITOPS rates. These efforts include programs to promote abstinence and delay the onset of early sexual activity and programs to increase the numbers of sexually active teens who use contraceptives effectively. 2. Maternal and Infant Health, Reproductive Health and Family Planning Introduction The health of mothers, infants, and children is of critical importance to a population, as this reflects not only the current health status of a large segment of the population, but also influences the health status of the future generation. The key maternal and infant health (MIH) indicators evaluated in this section are: pregnancy and birth rates; early prenatal care; late/no prenatal care; ITOPS/STOPS rates; maternal mortality; fetal deaths; low and very low birthweight; preterm births; and infant, neonatal, and postneonatal mortality. Based on these indicators, the overall status of maternal and infant health in the county is relatively good, and in many cases improving, with the exceptions noted in the following discussion. Certain indicators have also been assessed by ethnicity/race, age, and geographic zone in the county to permit comparisons to better identify health issues and disparities needing further assessment and community action. These within county comparisons do not include births or deaths that occurred in NYC for county residents. Pregnancies and Receipt of Prenatal Care In 2004-2006, 20,912 pregnancies were recorded for Orange County residents. There has been an overall decline in the pregnancy rate for females ages 15-44 in the county over the latest ten-year time period (1997-2006); this trend is consistent with that for Upstate. The pregnancy rate in the county is the second highest in the HVR, higher than the average for the region and Upstate, and lower than the rate for NYS. Access to early and ongoing prenatal care is important to healthy birth outcomes for women of all ages. The percentage of births to women who report receiving early prenatal care (within the first trimester) has remained fairly constant in Orange County over the ten-year period, however rates for early prenatal care remain consistently below those for Upstate, and at 69.6% for 2004-2006, do not meet the HP2010 target of 90%. Orange County rates for this indicator also fall below those for the HVR and NYS for the period 2004-2006. Evaluation of the percentage of births to women who report receiving late or no prenatal care (third trimester or none at all) showed a favorable decline in 3-year average rates from 1998-2006, however rates for 2004-2006 were above the HVR and Upstate averages. In terms of ethnic, racial, age and geographic differences for receipt of prenatal care within the county, in 2004-2006 White females were most likely to report early prenatal care (71% of total births), compared with 60.8% for Black/African American females and 62.6% for Hispanic/Latino females. Women ages 25 and over were more likely to report receipt of early prenatal care than were younger women. Geographically, the highest percentages of early prenatal care where reported by women residing in the West and East zones, with the lowest percentages for women residing in the three cities and Central zone (these differences were statistically significant compared with county averages). Note that these figures are based on the residence of the mother, but do not necessarily reflect where prenatal care was received. Since figures on the timeliness of receipt of prenatal care are based on information from birth certificates, pregnancies that result in fetal deaths are not included. (Exhibits 1A.52, 1A.48 a-d, 1A.49 a-e) Orange County Community Health Assessment 2010-2013 Section I 12

Births In 2004-2006, there were a total of 15,804 live births to county residents. The birth rate in the county has declined slightly over the ten-year period from 1997-2006, and remains higher than the rates for the HVR, Upstate and NYS. From 2004-2006, 29.7% of births were to unmarried mothers, compared with 28.9% for the HVR, 33.5% for Upstate and 39.2% for NYS. The majority of births to county residents of known race/ethnicity were to White mothers, followed by Hispanic/Latino and Black/African American mothers. Birth rates (number of live births/1,000 females ages 15-44) were highest in Hispanic/Latina females, followed by Black/African American females and lastly White females, and in women ages 25-34. Geographically, the city of Middletown ranked first in birth rate (ages 15-44) followed by the city of Newburgh. In contrast, in 2001-2003, White females had the second highest birth rate and of the county s geographic areas, the city of Middletown had the highest birth rate. (Exhibit 1A.53a-b) The percentage of Medicaid/Self Pay (or uninsured) births in the county in 2004-2006 was 37.6%, compared with 36.6% for the region and 31.7% for Upstate. Medicaid and Self Pay births are highest in teens, in minority women, and in the county s three cities and Central Zone (geographic differences were statistically significant). The highest rate (67.5%) is in the city of Newburgh, which is significantly higher than the overall county rate of Medicaid or Self Pay births. (Exhibit 1A.47a-d) The rate of births of short gestation, or preterm births (< 37 weeks gestation) has fluctuated over the ten year period of 1997-2006, and remained fairly stable. The 2004-2006 rate (11.3 percent/100 live births) is slightly below the rate for the HVR, Upstate, and NYS. This rate exceeded the HP2010 target of 7.6%. Preterm births as a percentage of total births within racial and ethnic groups were highest in Black/African American females, followed by Hispanic/Latino females and lastly White females. (Exhibit 1A.50a-e) Spontaneous Fetal Deaths (SFDS) and Induced Terminations of Pregnancies (ITOPS) The death of fetuses before birth is an important indicator of perinatal health. In addition to birth defects, fetal death sometimes is associated with complications of pregnancy, and early, comprehensive care to manage such conditions is critical to reduce fetal deaths. (Healthy People 2010) Rates of Spontaneous Fetal Deaths (SFDS) at 20+ weeks gestation have varied, and have shown a positive downward trend since 2001. The county rate for 2004-2006 showed marked improvement and fell below the HVR average, Upstate and the NYS average. The rate of 2.9 met the HP2010 target of 4.1/1,000 live births. Induced Terminations of Pregnancies (ITOPS), or abortion rates have remained fairly consistent in the county over the ten year period, with a slight increase since 2003. The ratio of induced abortions to live births in Orange County is comparable to ratios for the HVR and Upstate and lower than the rate for NYS. (Exhibit 1A.43, Community Health Data Set) Maternal Mortality Due to advances in prenatal care and obstetrical practices, maternal mortality, or death as a result of pregnancy and its complications, is a relatively rare event in the 21 st Century in industrialized nations. There were two maternal deaths in Orange County in the three year period of 2004-2006. The maternal mortality rate in Orange County is above the rate for the HVR and below that for the state, however this rate is unstable. The three-year average met the HP2010 target of 3.3/100,000 live births. (Exhibit 1A.54) Infant Mortality Figure 3 - ORANGE COUNTY INFANT MORTALITY RATE PER 1,000 LIVE BIRTHS Source: NYSDOH, Community Health Data Set 2006 Infant mortality is a key indicator of the health of a population. It reflects maternal health as well as the quality and accessibility of primary health care available to pregnant women and infants. In the U.S., the following account for more than half of all infant deaths: birth defects, disorders relating to short gestation and unspecified low birthweight (LBW), sudden infant death syndrome (SIDS), and respiratory distress syndrome. (Healthy People 2010) Early and consistent prenatal care is important in the prevention of infant mortality and for healthy birth outcomes. The infant mortality rate (IMR) has generally declined in the past decade in both NYS and Orange County, however as shown graphically in Figure 3, the county has seen a reduction in the 1997 IMR of 6.4/1,000 live births to the 2006 rate of 3.5, a substantial improvement. The county s single-year IMR in 2006 met the HP2010 target of 4.5/1,000. Infant mortality includes neonatal (less than 28 days old) and postneonatal (29 to 365 days old) mortality figures. The leading causes of neonatal death include birth defects, disorders related to short gestation and LBW, and pregnancy complications. Of these, the most likely to be preventable are those related to preterm birth and LBW, which represent approximately 20 percent of neonatal deaths. Postneonatal death reflects events experienced in infancy, including SIDS, birth defects, injuries, and homicide. Birth defects, many of Orange County Community Health Assessment 2010-2013 Section I 13

which are unlikely to be preventable given current scientific knowledge, account for approximately 17 percent of postneonatal deaths; the remainder are likely to stem from preventable causes. (Healthy People 2010) In the discussion of rates, it should be noted that both maternal mortality and infant mortality, which are fortunately rare events, can show dramatic shifts in rates with a small increase or decrease in the number of events from one year to the next. Infant mortality, neonatal mortality, and postneonatal mortality rates based on three-year averages declined from 2004 to 2005, and in 2006, all three were below the rates for Upstate. County rates in 2004-2006 for infant and neonatal mortality indicators are slightly above the regional average; county and regional rates are the same for postneonatal mortality during this time period. County rates for all three indicators are below the NYS average. The neonatal mortality rates (3.9/1,000 live births) and postneonatal mortality rate (1.5/1,000 live births) in the county are above the respective HP2010 targets of 2.9 and 1.2/1,000 live births. Based on a percentage of total births by known ethnicity/race, Black/African American infants have the highest percentage of infant deaths; Hispanic/Latinos the second highest percentage, and Whites have the lowest percentage. Differences in the infant mortality rate by race are consistent with both state and national findings. This disparity in part reflects higher teen birth rates, and other risk factors such as incidence of low birthweight and lack of early prenatal care. (Exhibits 1A.55,1A.56,1A.57,1A.58,1A.59,1A.60) Low Birthweight and Very Low Birthweight Low birthweight (LBW) infants are defined as those who weigh less than 2,500 grams (5.5 lbs.) at birth; very low birthweight (VLBW) infants weigh less than 1500 grams (3.3 lbs). Low birthweight (LBW) is a major risk factor for infant mortality and long term disability. Prevention of low birthweight is a major focus of public health and prenatal care programs. As defined in the Institute of Medicine s report, Preventing Low Birthweight, risk factors for LBW include: low socioeconomic status, low level of education, non-white race (particularly Black/African American), childbearing at extremes of age, poor obstetric history, poor nutritional status, inadequate weight gain, complications of pregnancy, multiple pregnancies, smoking, alcohol/substance abuse, absent or inadequate prenatal care, and certain infections, medical diseases and conditions in the mother. LBW is the primary risk factor associated with neonatal death; therefore improvements in infant birth weight should help to reduce infant mortality rates. Of all LBW infants, VLBW infants are at highest risk of dying in their first year of life. (Healthy People 2010) From 1997-2006, Orange County s rates for both LBW and VLBW have remained relatively stable, with a slight upward trend for LBW since 2003 based on three-year averages. Rates for LBW and VLBW in Orange County were below the rates for the HVR, Upstate and NYS in 2004-2006. Orange County had the second lowest rate of LBW in the HVR from 2004-2006 (7.1 per 100 live births; average for HVR is 7.6). The percentage of LBW infants/100 live births in 2006 was 6.7%, which exceeded the HP2010 target of 5%; the rate for VLBW in the county (1%) also exceeded the HP2010 target of 0.90%. Rates of LBW are higher in Black/African American females, which is consistent with findings in NYS and the nation. Rates of LBW are higher in teens, and in women ages 45 and over, as previously discussed. Geographically, the highest rates of low birthweight in the county based on zone are in the cities of Newburgh and Middletown (both are 8.8%). The highest percentages of births to females ages 17 and under and late/no entry into prenatal care were in the city of Newburgh. The highest rate of pre-term births was found in the city of Port Jervis. (Exhibits1A.46a-d, 1A.49a-e, 1A.50a-e, 1A.51a-e, 1A.61) Family Planning Inferences about the availability of family planning and/or consistent use of family planning methods can be made from examination of the recent ITOPS rates in Orange County. In 2004-2006, there were 4,503 induced abortions compared with 15,804 births, or a ratio of 28.5 per 100 live births. This rate is slightly higher than that for the HVR and well below that for Upstate, and may suggest the need for improved access to or utilization of family planning services. Use of contraceptive methods by Orange County residents ages 18 and over is also addressed in Section 1C. Behavioral Risk Factors. Substance Abuse in Pregnancy A range of effects, including spontaneous abortion, LBW, and preterm delivery, are associated with prenatal use of tobacco, alcohol, and other drugs. Trends in tobacco use during pregnancy are discussed in Section 1C Behavioral Risk Factors. The prevalence of substance abuse in pregnant women can be assessed in part by examination of newborn drug-related discharge rates. Rates for Orange County newborns in 2004-2006 are much lower than Upstate and NYS, and also lower than the average rate for the HVR. It should be noted that these rates are highly sensitive to any regional variations in identification and diagnosis of drug use at different hospitals. The three-year average and annual rates for this indicator have fluctuated, and warrant continued monitoring. (Exhibit 1A.62) 3. Intentional and Unintentional Injuries The principal causes of intentional injuries include domestic violence, suicides and homicides; the principal causes of unintentional injuries include motor vehicle accidents, pedestrian and bicycle accidents, falls, fires, suffocation, and drowning. Unintentional injuries, or accidents, are the leading cause of death in Orange County residents under the age of 25. More adolescents die each year from accidents than all other causes of death combined. The causes of various types of injuries vary with ages, with motor vehicle accidents being the primary cause in younger age groups, and falls in the elderly. Unintentional injuries occur disproportionately among young and elderly persons. Orange County Community Health Assessment 2010-2013 Section I 14

There has been an increase in the incidence rate of domestic violence reporting and arrest rates in Orange County, as well as in the region and state. (Exhibit 1A.63) The local domestic violence agency s hotline (Safe Homes of Orange County) received an average of 1,140 calls annually from 1999-2000, in 2008 this had increased to nearly 5,000. With the economic downturn, domestic violence has increased as reported by local police departments; Safe Homes has experienced an increase in call volume of over 100 calls per month. Safe Home s shelter has been at capacity and requests for sheltering have increased. In 2008 Safe Homes provided direct service and advocacy to 2,500 women and over 700 children. (Children, Youth and Families Profile and Orange County Community Profile Needs Assessment @ www.co.orange.ny.us; Safe Homes Domestic Violence and Health Fact Sheet, 2009) Hospitalization (hospital discharge rates) due to assault (all types) in Orange County had an upward trend since 2002, and is slightly above the Upstate rate. In 2004-2006, the county rate was the same as the HVR average, and well below the NYS average. Death due to homicide is an infrequent event in the county, so rates are highly variable from one year to the next. The 2004-2006 adjusted rate is below the average for the HVR and NYS. The homicide death rate (2.3/100,000) in the county met the HP2010 target of 2.8/100,000). (Exhibit 1A.64, Community Health Data Set) Trends in mortality from unintentional injury, or accidents, show that overall rates in Orange County are lower than for Upstate. Rates are higher in males (26.3/100,000) compared with females (14.5/100,000). Mortality rates from unintentional injury have fluctuated, and have remained below the Upstate rate since 2003. County adjusted mortality rates from unintentional injury were above those for the HVR and the state for the most recent three year period (2004-2006). Rates of hospitalization for unintentional injury (all ages) from 1997-2006 show a gradual upward trend; adjusted rates for 2004-2006 are above the average for the HVR and those for NYS. Adjusted discharge rates for adults ages 65 and over were considerably higher than the rates for Upstate, NYS and the HVR in 2004-2006. Adjusted rates of hospitalization for traumatic brain injury (all ages) in 2004-2006 were identical to those for the HVR, and slightly above NYS rates. The county adjusted rate for traumatic brain injury hospitalizations (8.3/10,000 or 83.0/100,000) exceeds the HP2010 target of 41.2/100,000. Adjusted mortality rates from unintentional injury (26.7/100,000) and motor vehicle accidents (12.0/100,000) in the county both exceed the respective HP2010 targets (17.5 and 9.2/100,000). (Exhibits 1A.65a-b, 1A.66, 1A.67, 1A.68, 1A.69, 1A.70) The annual death rate from motor vehicle accidents (MVA) has increased in Orange County since 2000, with a decline from 2005 to 2006. Rates in 2006 were slightly higher that Upstate rates. MVA mortality rates in the county were also higher than those for the HVR and state for the time period 2004-2006. Rates of alcohol-related motor vehicle deaths and injuries in the county exceed average rates for the region and for the state during this same time. (Exhibit 1A.68) The county rate of 67/100,000 population far exceeds the HP2010 target of 4.0/100,000, as do the rates for the HVR, Upstate and NYS. As reported in Healthy People 2010, use of safety restraints and not driving while under the influence of drugs or alcohol are two of the most effective means to reduce the risk of death and serious injury from motor vehicle accidents. According to 2007 data from the NYS Institute for Traffic Safety Management and Research, males in general (and drivers ages 29 and under specifically) had a disproportionate share of alcohol-related fatal and personal injury accidents in the county. (www.nysgtsc.state.ny.us) B. Disease Control 1. Sexually Transmitted Diseases Introduction Sexually transmitted diseases (STDs) may be caused by more than 25 infectious organisms. STD prevention is integral to improving reproductive health. STDs cause many harmful complications, such as reproductive, fetal and perinatal health problems, and cancer. STDs are behavior-linked diseases that are spread through sexual activity or through blood, particularly among intravenous drug users sharing equipment. Women can also transmit STDs to their children during pregnancy, labor, or delivery. Women are at higher risk than men for most STDs, and younger women are more susceptible to certain STDs than are older women. STDs disproportionately affect the poor, persons who engage in risky sexual behavior, and when access to reproductive health care is limited. Some disproportionately affected groups include sex workers (people who exchange sex for money, drugs, or other goods), adolescents, persons in detention, and migrant workers. (Healthy People 2010). Publicly supported STD Prevention and Control Programs, such as those operated by OCDOH described in Section II Local Health Unit Capacity, help to assure that screening, early diagnosis, and prompt treatment of STDs are available to prevent complications and further transmission within the population. These services include an active partner notification program to ensure all sexual contacts of infected persons receive prompt screening and treatment. Syphilis The incidence of syphilis in county residents is very low, and as a result rates fluctuate considerably from one year to the next. In 2008, there were 9 cases of early syphilis and 4 cases of late syphilis in Orange County residents. In 2007, there were 8 cases of early syphilis and 7 cases of late syphilis. This compares with 14 cases of early syphilis in 2004-2006 (10 of which were reported in 2004); and 47 cases of late syphilis. There were no cases of early syphilis reported in adolescents ages 15-19 in the county. The 2007 case rates for both early and late syphilis were below the Upstate and NYS rates. The 2004-2006 rates for early syphilis in the county were below the rate for the HVR and state. There was one case of congenital syphilis reported in the county in 2004-2006. (Exhibit Orange County Community Health Assessment 2010-2013 Section I 15

1A.71) Syphilis is highly treatable if detected early - access to preventive education, early screening, detection, and treatment are critical, including women at risk for pregnancy to prevent congenital syphilis. Gonorrhea In 2008, there were 170 cases of gonorrhea reported in Orange County residents, which is higher than the 2005-2007 average number of cases (128). Additional educational efforts are needed to reach at-risk teens with both prevention messages and screening and detection services. The case rate for 2004-2006 (38.5/100,000) was similar to the average rate in the HVR, and exceeded the HP2010 target of 19 new cases per year/100,000 population. (Exhibit 1A.72) Chlamydia Chlamydia, which became reportable in NYS in 2000, is the most prevalent sexually transmitted disease in the county. The most common age range for Chlamydia diagnosis in the county is 15-19 (55% of cases in 2004-2006). Chlamydia presents a major public health challenge, as the vast majority of females and up to half of males who are infected are symptom-free. A major consequence of untreated Chlamydia infections is the development of pelvic inflammatory disease (PID). In 2008, 821 cases of Chlamydia were reported in the county, yielding a case rate of 218, which is well below the rate for Upstate and NYS. In 2004-2006 the case rate for males and females in Orange County was below that for the HVR. The female case rate in the county is more than 3 times the rate for males, owing in part to screening of at risk women as part of routine reproductive health visits. From 2004-2006 there were 425 cases of Chlamydia reported in males; in females there were 1,445. (Exhibit 1A.73) Pelvic Inflammatory Disease (PID) PID is caused most frequently by chlamydial infections and gonorrhea, and as such rates of hospitalization for PID are a marker for early diagnosis and effective treatment for these conditions in females. PID poses a serious threat to female reproductive capability, as it is a major cause of both ectopic pregnancy and infertility. (Healthy People 2010) The average hospital discharge rate in 2004-2006 was slightly higher than the HVR, and well below the rate for NYS. (Exhibit 1A.74) 2. HIV/AIDS First emerging as an infectious disease in the county in 1982, HIV Infection and AIDS remain a significant cause of illness, disability, and death throughout NYS, especially in NYC, and in the county. In 2007, there were 26 cases of AIDS and 53 newly diagnosed cases of HIV reported in Orange County. The number exceeds the HP 2010 target of one new case of AIDS per year/100,000 population. The AIDS case rate for 2004-2006 in Orange County (10.8/100,000) was below that for the HVR and NYS. In 2007, the case rate for the county (6.9/100,000) was below that for Upstate (7.6), and well below that for NYC (38.2) and NYS (20.6). (Exhibit 1A.75a-c) Based on the May 2008 NYS HIV/AIDS Surveillance Annual Report, there were 1,058 persons living with HIV and AIDS in the county through December 2007 (including prisoners). (www. health.state.ny.us/diseases/aids/statistics) Using a composite health index, the NYSDOH Community Need Index Report designates 9 zip codes in the county as high need for planning, education, and service efforts based on rank ordering of all county zip codes. The top three zip codes include 12550 (Newburgh city), 10940 (Middletown city), and 10918 (Chester). It should be noted that closure of the Camp LaGuardia homeless facility in Chester may impact the future designation of this zip code as high need. The proportion of different population groups affected by HIV/AIDS has changed over time in the nation, state, and county. Initially most prevalent in White gay and bisexual men, HIV/AIDS is increasingly appearing in females and in minorities who are contracting the disease through injection drug use (IDU) and unprotected heterosexual sex with high risk partners. Groups at highest risk for HIV infection in the county include: Men in who have sex with men (MSM); Injection drug users; Heterosexual persons in high risk groups including (1) injection drug users, (2) persons with STDs that can increase both susceptibility to and transmissibility of HIV infection, and (3) persons with multiple sex partners who engage in high-risk sexual practices (mainly unprotected sex) associated with substance abuse, prostitution and sex in exchange for drugs or other goods. Data for the Mid-Hudson Ryan White Region, provided by NYSDOH for newly diagnosed cases in Orange, Dutchess, Sullivan, and Ulster Counties from January December 2006 show the following: The total number of newly diagnosed AIDS cases in the civilian population was 94; 70 (74.5%) of these were males and 24 (24.5%) were females. For HIV, the total number of newly diagnosed cases was 234; 70.1% were males and 29.9% were females. The ethnic/racial distribution of newly diagnosed AIDS cases was 34% White, 35.1% Black/African American, and 23.4% Hispanic/Latino. For HIV cases, the distribution was 30.3% White, 35.0% Black, and 28.6% Hispanic/Latino. Rank order risk categories in newly diagnosed AIDS cases were IDU (28.7%), MSM (26.6%), heterosexual contact (23.4%), unknown (14.9%) and MSM/IDU (5.3%). This represents a considerable increase in transmission through heterosexual contact and decline in IDU transmission over time. For newly diagnosed HIV cases the rank order risk categories were unknown (46.2%), MSM (37.2%), heterosexual contact (12.0%), IDU (3.4%) and MSM/IDU (1.3%). For cumulative HIV cases the risk categories were unknown (47.2%), heterosexual (35.7%), MSM (26.4%), MSM/IDU (33.3%), and IDU (25%). The highest prevalence rate for both living with HIV and AIDS is in ages 40-59. Males, persons ages 40-59, Black/African Americans, Hispanic/Latinos, and MSM risk were Orange County Community Health Assessment 2010-2013 Section I 16

associated with late diagnosis in the region (AIDS within 1 year of HIV diagnosis). With advances in highly active antiretroviral therapy (HAART) treatment, the time period in which HIV progresses to AIDS has increased. For disease surveillance, tracking of HIV infection is a much more sensitive measure than is tracking of AIDS. HIV infection became reportable in NYS in 1998, and this has improved the ability of Health Departments to monitor the frequency of infection among various risk groups, and to provide timely notification of partners. Reported HIV infection rates for 2003-2005 (excluding State Prison Inmates) in the county are higher than those for the HVR and Upstate. (Exhibit 1A. 75 a-c) Advances in testing, such as the availability of highly accurate oral testing, will hopefully improve access by hard to reach groups, as testing can now be provided in non-clinical, community sites by trained HIV counselors. As noted in Section II- Local Health Unit Capacity Profile, the OCDOH HIV Prevention and Education Program provides HIV counseling and testing utilizing OraSure; testing services are focused in high risk settings. Advances in treatment of HIV infection and AIDS have also resulted in a reduction in the mortality rate from AIDS. Analysis of time trends show a downward trend in AIDS mortality rates since 1997; from 2004-2006 the rate is comparable to the average for the HVR, slightly above the rate for Upstate and lower than the rate for NYS. (Exhibits 1A.75a-c, 1A.76a-b) Despite this improvement, in 2004-2006 AIDS was the fifth leading cause of death in Orange County residents ages 25-54 (total of 14 deaths). (Exhibit 1A. 35) Perinatal AIDS transmission is preventable through HIV screening and appropriate treatment with zidovudine therapy during pregnancy. HIV counseling and testing is recommended by NYSDOH as a standard of care for all pregnant women. By law, all newborns in NYS are screened for HIV. Pregnant women at highest risk for not accessing prenatal care (injectable drug users who engage in risky sex practices) also fall into the highest risk categories for HIV Infection/AIDS. Outreach to high risk populations who are at risk for pregnancy, such as substance abusing adolescents and women, is critical to prevent perinatal AIDS transmission. In Orange County, this is provided through a collaboration of agencies including the OCDOH HIV program, CHCs, and AIDS Related Community Services (ARCS). In 2001-2003, the county s rate of HIV positivity in newborns in was below that for the HVR and NYS. (Exhibit 1A.77) 3. Tuberculosis In 2008, Orange County had 7 reported cases of Tuberculosis (TB), the same as the previous year. There were no multi-drug resistant TB cases reported in the county in the period 2000-2008. TB rates in the county in 2004-2006 were lower than those in the HVR; rates in the HVR were highest in those counties closest to NYC (Westchester and Rockland). The rate in 2004-2006 exceeded the HP2010 target of 1 new case/100,000. The county s TB rate in 2007 was lower than that for Upstate, and well below the rate for NYS. (Exhibit 1A.78a-b) The OCDOH Tuberculosis Prevention and Control Program monitors all cases to assure completion of recommended treatment. In 2007-2008, an average of 92% of cases in the county completed their recommended course of treatment (HP2010 target 90%). All active TB cases are followed until completion of treatment unless they leave the County. TB Clinics provide screening, prophylaxis for contacts of cases, and treatment services for cases and latent TB infection (LTBI), including directly observed therapy. As TB is overrepresented in minority, foreign-born, and low income populations, clinics are located in areas with a high number of recent immigrants to facilitate utilization of these services. 4. Other Communicable Diseases Introduction This section discusses selected reportable communicable diseases not addressed separately elsewhere in this report. Comparative data (County, HVR, ROS, and NYS) for selected reportable communicable diseases in 2004-2006 are provided in Exhibit 1A.79. OCDOH services related to the prevention and control of communicable diseases are discussed in detail in Section II Local Health Unit Capacity. Disease prevention, surveillance, monitoring, and control activities are essential to the protection and preservation of health in the community and are core services provided by clinic, outreach, health investigation, and home health nursing staff within the Health Department. Hepatitis The incidence of Hepatitis A in the county in 2008 met the HP2010 target of no more than 4.3 new cases/100,000; in 2008 there was 1 case compared with 2 cases in 2007. In 2004-2006 there were a total of 7 reported cases. There were 3 new cases of Acute Hepatitis B reported in 2008 which is consistent with the 2005-2007 average case number of 2. Chronic Hepatitis B cases in 2008 numbered 11, which is lower than the 2005-2007 average case number of 20. There were 311 newly identified cases of chronic Hepatitis C reported in 2008, which is less than the average number of cases reported in 2005-2007 (340). Tickborne Diseases - Babesiosis, Ehrlichiosis, and Lyme Disease Lyme disease is by far the most prevalent tickborne disease reported in Orange County residents. In 2004-2006, 1,521 cases were reported in the county. In 2007, Orange County Department of Health participated in a pilot sentinel surveillance system for Lyme disease. This involved investigation of 20% of all Lyme disease laboratory reports and 100% of all provider reported cases of Lyme disease. The New York State Department of Health extrapolated the data resulting in 529 cases. In 2008, the number of cases of Lyme disease was 533. In 2009, NYSDOH implemented the successful Lyme disease sentinel surveillance system in 19 Lyme endemic counties throughout the State, including Orange County Community Health Assessment 2010-2013 Section I 17

Orange County. Sentinel surveillance allows for accurate detection of disease in the County while using health department staff more efficiently and reducing the reporting burden on community physicians. Lyme disease case rates for Orange in 2004-2006 (407.9) exceeded the rate for the HVR, Upstate and NYS, and the HP 2010 target of a 5-year annual average of 9.7 new cases/100,000. In 2007, Orange ranked fourth of the 7 HVR counties in the rate for Lyme (NYSDOH estimated rate) rates were highest in Ulster County, followed by Dutchess and Putnam Counties. Twenty cases of Ehrlichiosis were reported in Orange County from 2004-2006; the number of cases of Ehrlichiosis reported in 2007 12 cases; and in 2008 15 cases. Babesiosis is a tickborne and bloodborne illness most commonly transmitted to humans by deer ticks. In 2007, the county with the highest number of cases in the HVR was Dutchess (44 cases) followed by Westchester (29 cases); there were 5 cases diagnosed in Orange County. In 2008, there were 7 cases of Babesiosis identified in county residents.(nysdoh) Meningococcal Disease Four cases of meningococcal disease were reported in county residents from 2004-2006. In 2007 there were 2 new cases, and in 2008 there were no reported cases. The rate for 2004-2006 was comparable to that for the HVR, Upstate, and NYS, and exceeded the HP2010 target of no more than 1 case/100,000. Case rates for viral meningitis were above those for the HVR, but below rates for both Upstate and NYS from 2004-2006. (Exhibit 1A.79) Enteric and Foodborne Diseases OCDOH works closely with the community to help control transmission of enteric and foodborne diseases and provide preventive education. Salmonellosis was the most frequently reported enteric communicable disease in Orange County in 2004-2006 (143 cases). In 2007 there were 56 cases; 48 cases were reported in 2008. The county rate in 2004-2006 was comparable to the HVR, slightly above Upstate, and below the NYS rate. Shigellosis was the next most frequently reported during 2004-2006 (70 cases); 85 cases were identified in a multi-county outbreak in 2008. The rates for Camplylobacteriosis, Escherichia coli O157:H7 and Giardiasis were lower in the County than in the HVR, Upstate and NYS in 2004-2006. (Exhibit 1A.79) In terms of less common enteric and foodborne diseases, an average of 3 cases/year of cryptosporidiosis and an average of one new case of cyclosporidiosis were reported in the county in 2006-2008. In cooperation with NYSDOH, the OCDOH Divisions of Public Health Nursing and Environmental Health Services conduct thorough and comprehensive investigations for all foodborne outbreak investigations. The last foodborne outbreak in the county was in 2002, and Yersinia was isolated from one case. There was one case of infant Botulism in the county in 2003, a highly rare occurrence, which was of undetermined cause. Group B Streptococcal Invasive Infection and Streptococcus Pneumonia Twenty-eight cases of Group B Streptococcal Invasive Infection were reported in the county in 2004-2006; the rate was well below the rate for the HVR, Upstate, and NYS. In 2007, 13 cases were reported in county residents; 22 cases were reported in 2008. Rates for non-drug resistant and drug resistant Streptococcal pneumonia were similar to those for the region from 2004-2006; county rates were lower than Upstate and higher than those for NYS. In 2007, 30 cases were reported in county residents; 47 cases were reported in 2008. (Exhibit 1A.79) Rabies Orange County was one of the first counties to become affected by the raccoon rabies epizootic when it entered New York State from Pennsylvania in 1990. The disease has continued to be endemic in wild animal populations (especially raccoons and skunks) and as such has been a constant threat to domestic animals and county residents. Public education efforts, intensive camp counselor training in summers, animal testing, and strict adherence to NYSDOH protocols for rabies prophylaxis following exposures all help prevent human rabies cases. In 2007, 134 County residents received post-exposure prophylaxis; and 94 persons received post-exposure prophylaxis in 2008. 5. Vaccine Preventable Diseases Due to combined national, state, and local health efforts, the incidence and rates of most vaccine preventable diseases have declined over the past decade. Vaccines protect the vaccinated individual and the spread of disease in the community. If vaccination levels in a community are high, others who cannot be vaccinated are indirectly protected because of group or herd immunity which quells the spread of disease. As discussed in this section under Family Health, the goal of the OCDOH IAP is to achieve full immunization coverage for the county s children by age 2. OCDOH works with pediatric health providers and community health centers throughout the county to meet this goal. In addition to infants and school age children and adolescents, OCDOH Immunization clinics serve college students, and international travelers. Results from provider assessments in 2008 show 86% coverage for 4:3:1 (4DTaP, 3 Polio, 1 MMR) and 84% coverage for 4:3:1:3:3 (4DTaP, 3 polio, 1 MMR, 3 Hib, 3 Hep B) in the practices surveyed which meets the HP2010 target of 80% for 4:3:1:3:3. As immunization is required for school entry with few exceptions, coverage rates at kindergarten entry are consistently high throughout NYS. The 2007-2008 school immunization survey conducted by NYSDOH showed that 96% of kindergarten students in the County had received the complete immunization series, meeting the HP2010 target of 95%. In terms of recent rates and cases of vaccine preventable diseases, there were no cases of measles reported in the county in 2004-2008. There was 1 case of Mumps reported in 2004-2006; no cases were Orange County Community Health Assessment 2010-2013 Section I 18

reported in 2007-2008. Pertussis rates in the county are a concern as they were higher than the average in the HVR and NYS from 2004-2008. A total of 214 confirmed and probable cases were reported during 2004-2006; 19 confirmed and probable cases were reported in 2007, and 40 were reported in 2008. The majority of these cases were in children and adolescents. There may be a decrease in Pertussis immunity over time, which leads to infection in previously immunized individuals that can potentially spread the disease to incompletely protected persons. No cases of Rubella or Congenital Rubella have been reported in the county from 2004-2008. In 2004-2006, there were 8 cases of Haemophilus Influenza in the county; in 2007 there were 5 cases, and in 2008 there were 4 cases. A contributing factor may be the shortage of Hib vaccine which began in December 2007 and resulted in the CDC recommendation to temporarily defer the Hib booster for non-high risk children ages 12 to 15 months until supplies are restored. There continue to be no reports of diphtheria, poliomyelitis, and tetanus in the county, which meets HP2010 target of zero cases per year. Pneumonia still remains a leading cause of death in older adults in the county, ranking fifth in adults ages 75 and over. From 2004-2006 there were 253 deaths in the county from pneumonia; all were adults. Pneumonia (pneumococcal) vaccination is recommended for high risk children and adults and for all healthy adults ages 65 and over, and in addition to health care settings, is provided in OCDOH immunization and annual flu clinics. Avoiding the unnecessary use of antibiotics is an important control measure in the development of drug-resistant strains of this disease. (Exhibit 1A.80) 6. Chronic Diseases Introduction Due to advances in both the prevention and treatment of infectious diseases, chronic diseases now account for the majority of adult deaths in Orange County (Exhibit 1A.34). As discussed earlier in this section, the primary causes of death differ by age; however from age 45 forward, chronic diseases are the primary and secondary causes of death for adults in Orange County, NYS, and the nation. Chronic diseases are in general non-communicable and degenerative in nature. They are characterized by multiple and interacting risk factors, and in addition to being the major cause of death in adults, they are the major causes of disability. Some risk factors for chronic diseases such as inherited factors, age, and gender are not controllable. Other risk factors such as smoking, alcohol and other drug use, diet and exercise patterns, obesity/overweight, high blood pressure, and elevated blood cholesterol can be modified, and often interplay as contributing factors to a number of chronic diseases. Therefore, improvements in life-style involving healthier diets, increased physical activity, smoking cessation, and avoidance of drugs and overuse of alcohol have a universal beneficial effect on reducing the incidence and prevalence of chronic illnesses. Thus, the major thrust of public health efforts to reduce chronic diseases and the 2008 NYS Prevention Agenda is preventive health education, screening, and early detection. Behavioral factors that can be modified to reduce risk for chronic diseases are overviewed in Section 1C Behavioral Risk Factors. In addition to the health promotion and risk reduction services described in Section II - Local Health Unit Capacity, OCDOH actively partners with a broad coalition of agencies to reduce the incidence and prevalence of chronic diseases in the county. (See Section III- Profile of Community Resources) Cardiovascular Diseases Cardiovascular diseases (CVD) encompass a group of disorders that damage the cardiovascular system the heart and blood vessels. They include coronary heart disease, cerebrovascular disease or stroke, atherosclerosis, congenital heart disease, and hypertension, or high blood pressure. The two major subcategories of CVD are diseases of the heart and cerebrovascular disease. Trends in mortality rates from CVD have steadily declined in the county since 1999, and in 2006, were at a ten-year low. As seen in Figure 5, the mortality rate from CVD in Orange County has consistently remained below the rate for Upstate since 1997. The current adjusted rate of 271.1/100,000 is less than the Upstate and NYS rate and slightly higher than the HVR average for 2004-2006. In 2004-2006, Orange County males had higher mortality rates from CVD than did females. In persons of known race/ethnicity, Black/African Americans had the highest mortality rates, followed by Whites and lastly Hispanic/Latinos. CVD mortality rates increase substantially with advancing age in age groups 65 and over. The city of Newburgh had the highest CVD mortality rate of the geographic zones in the county, followed by Port Jervis; these rates were statistically different than those for all other zones including the city of Middletown. (Exhibits 1A.81, 1A.82a-d) Figure 4 Source: NYSDOH, Community Health Data Set 2006 Prevention Quality Indicators Circulatory conditions are one of 4 categories of Prevention Quality Indicators (PQIs) developed by New Orange County Community Health Assessment 2010-2013 Section I 19

York State Department of Health. These indicators can be used to evaluate excess hospital admission rates for acute and chronic conditions in adults that are amenable to preventive and primary care. County agesex adjusted rates can be compared with statewide rates for composite indexes in 4 areas: acute, diabetes, circulatory, and respiratory. Review of county vs. state hospital admission rates for conditions included in the circulatory composite index (hypertension, congestive heart failure, and angina) showed that county rates were 4% above those expected (104%); with admission rates more than 10% above those expected for residents of the county s three cities Newburgh (148%), Port Jervis (118%) and Middletown (111%). (Exhibit 1A. 83) Diseases of the Heart and Cerebrovascular Disease Coronary heart disease (CHD) and stroke have several common risk factors, including high blood pressure, cigarette smoking, high blood cholesterol, and overweight. Physical inactivity and diabetes are additional risk factors for CHD. The lifetime risk for developing CHD is very high in the United States - one of every two males and one of every three females aged 40 years and under will develop CHD at sometime later in their lives. (Healthy People 2010). In Orange County, the mortality rate from diseases of the heart has declined steadily since 1999, and has remained well below the rate for Upstate since 1997 (Figure 5). Data for 2004-2006 show that the rate is below the rate for the HVR, Upstate, and NYS. CHD mortality rates in the county (212.7/100,000) exceeded the HP2010 target of 162/100,000 population. (Exhibit 1A.84a-b) Figure 5 and Port Jervis had the highest rates of heart disease mortality; these rates were statistically elevated above the rates for other zones including the city of Middletown. In 2004-2006, diseases of the heart were the primary cause of death in Orange County residents ages 75 and over, and ranked second in adults ages 45-74. (Exhibit 1A.35) Nationally, heart disease mortality has been historically higher in males than in females and higher in the Black/African American population than in the White population. Disparities also exist in treatment outcomes by gender for persons who have had heart attacks - females generally have poorer outcomes than do males. Nationally, the male-female disparity in stroke deaths has narrowed. Although stroke mortality rates have been declining, the decrease in Blacks/African Americans has not been as great. Ageadjusted stroke mortality is almost 80 percent higher in Blacks/African Americans than in Whites and about 17 percent higher in males than in females. The number of existing cases of high blood pressure is nearly 40 percent higher in Blacks/African Americans than in Whites, a major contributing factor in stroke. (Healthy People 2010) As shown in Figure 6, the mortality rate from cerebrovascular disease (stroke) has remained below the Upstate rate over the 10-year period from 1997-2006; the rate is above the average for the HVR and NYS for 2004-2006. The ten-year trend for cerebrovascular disease is not as encouraging as that for heart disease. Both the HVR and Orange County mortality rates are above that for NYS. Mortality rates from cerebrovascular disease for subgroups and zones within the county were higher in males and in persons ages 85 and over, and in the Central, East, and North geographic zones. Deaths due to cerebrovascular diseases ranked as the fourth highest cause of death in county residents ages 75 and over. Mortality rates for stroke (38.1) met the HP2010 target of 50.0/100,000. (Exhibits 1A.82 a-d, 1A. 85a-b) Figure 6 Source: NYSDOH, Community Health Data Set 2006 In reviewing mortality for heart disease for subgroups and zones within the county, the heart disease mortality rate was higher in males than females, and higher rates were seen in Blacks/African Americans, followed by Whites and lastly Hispanics/Latinos. As previously mentioned, caution should be exercised in interpreting the rate information for Hispanic/Latinos due to the potential of underreporting ethnicity on death certificates. Residents of the cities of Newburgh Source: NYSDOH, Community Health Data Set 2006 Orange County Community Health Assessment 2010-2013 Section I 20

Cancer All Cancers Combined Cancer ranks second only to heart disease as the leading cause of death in Orange County. Nearly 25% (24.9%) of deaths in the county are attributable to cancer, compared with 28.1% being attributable to heart disease. Cancer resulted in 1,824 deaths to county residents in 2004-2006, and was the primary cause of death in Orange County adults ages 25-74. Since medical providers in New York State are required to report diagnosed cancers, cancer incidence data (number of new cases each year per 100,000 residents) are available only for this chronic disease. The most recent comparative data for cancer incidence and mortality in Orange County residents from the NYS Cancer Registry is for the five-year time period from 2001-2005. Rates for cancer incidence were significantly higher for Orange County residents than NYS for both males and females; mortality rates for females were also significantly higher than NYS female rates. NYS and county age-adjusted incidence rates decreased for both genders in 2001-2005 from the previous 5 year period (1997-2001). Age-adjusted cancer mortality rates improved in both NYS and the county for both genders from the previous 5 year period, with males showing the greater percentage reduction. In NYS, the mortality rate for males from all malignant neoplasms decreased by 9.5%, compared with a decrease of 7% in females. In Orange County, the corresponding reduction in cancer mortality rates for males was 5.3% and 3.6% for females during this same time. Males in the county had significantly higher rates of both cancer incidence and mortality from all cancers combined than did females, which is consistent with findings for NYS. The overall mortality rate for cancer for males (234.4/100,000) and females (179.6/100,000) in the county, although reduced substantially from 1997-2001, remained above the HP2010 target of 158.6/100,000 (Exhibits 1A.86, 1A.87). Analysis of age-adjusted cancer incidence rates by site and gender from the NYS Cancer Registry for 2001-2005 yield the following key results: cancer incidence in the county is 20% or more above the state rate for kidney/renal pelvis and thyroid cancer in females (both are statistically significant). The five-year average rate for thyroid cancer for males, although 20% above the state rate, does not reach statistical significance. Rates for oral and pharynx cancer and liver/intrahepatic bile duct cancer were 20% or more below state rates for females; the rates for liver/intrahepatic bile duct cancer were statistically significant. (Exhibit 1A.88a-b) Comparison of overall cancer mortality in county demographic and geographic subgroups presented in Exhibit 1A.89a-c. show that mortality from cancer is higher in males than females, and in Whites, followed by Black/African Americans, and lastly Hispanic/Latinos. In 1998-2000, Black/African Americans ranked first in overall cancer mortality in the county. Again, caution should be exercised in interpreting the data for Hispanic/Latinos due to the potential for underreporting of ethnicity. In terms of age, mortality from cancer increases with advancing age, and is highest in person ages 75 and over. The East, North, and West zones of the county had the lowest rates of overall mortality from cancer; mortality rates were highest in the cities of Port Jervis and Middletown; this difference was statistically significant. Lung & Bronchus Cancer Lung cancer is the primary cause of cancer deaths for both males and females in Orange County, NYS, and in the U.S. In 2002-2006 there were 846 deaths attributed to lung cancer in the county. The primary risk factor for lung cancer is tobacco use (smoking is estimated to be responsible for 80% of lung cancers). Mortality rates for lung cancer are estimated to be 23 times higher in current male smokers and 13 times higher in current female smokers when compared with persons who have never smoked. (American Cancer Society Region 7: Cancer Control Priorities & Priority Population Summary for FY 2004). After 10 years of abstinence, smoking cessation decreases the risk of lung cancer to 30-50 percent of that of persons who continue to smoke. (Healthy People 2010) The mortality rate for lung and bronchus cancer in the county has declined since 2004, and has been consistently lower than the rate for Upstate. The rate is above that for the HVR and NYS from 2001-2005. The lung and bronchus cancer mortality rate for males (69.1/100,000) exceeded the HP2010 target of 44.9/100,000; the mortality rate for females (44.7/100,000) nearly met this target. Data for 2001-2005 show that the incidence rate for lung and bronchus cancer is also higher for both males and females in the county than in the HVR and NYS. (Exhibits 1A.90, 1A.91a-e) Breast and Cervical Cancer Breast cancer is the most common cancer among women in the county (highest incidence rate). Many breast cancer risk factors, such as age, family and reproductive history, previous breast disease, race, and ethnicity, cannot be modified. Other factors like avoiding overweight and obesity can be addressed. Most cervical cancer in the U.S. may result from infections of the cervix with certain types of sexually transmitted human papilloma virus. Early detection through routine screening can reduce mortality from both breast and cervical cancer. (Healthy People 2010). As shown in Figure 7, there has been a desirable downward trend in breast cancer mortality in women in the county since 2004, and the rate in 2005-2006 was below that for Upstate. Comparisons of mortality rates for 2001-2005 show that county rates were slightly above those for NYS and the HVR. The breast cancer mortality rate in females in Orange County (26.6/100,000) exceeded the HP2010 target of 22.3/100,000. In 2002-2006 there were 230 deaths due to breast cancer in the county. Incidence rates for 2001-2005 were comparable to those for the HVR and above those for NYS, which means the rate of new cases diagnosed per year was more than state average for this 5 year period. (Exhibits 1A.90, 1A.91a-e) Orange County Community Health Assessment 2010-2013 Section I 21

Figure 7 - ORANGE COUNTY FEMALE BREAST CANCER DEATH RATE PER 100,000 FEMALES Source: NYSDOH, Community Health Data Set 2006 Trends in cervical cancer mortality rates in females in the county have been variable from 2002-2006 due to the relatively low number of events (26 deaths). Incidence rates for cervical cancer were above the rates for the HVR and NYS; in 2001-2005, mortality rates were above NYS and the HVR. Mortality rates for cervical cancer (2.9/100,000) exceeded the HP2010 target of 2.0/100,000. (Exhibits 1A.90, 1A.91a-e) Colorectal Cancer Colorectal cancer (CRC) is the second leading cause of cancer death in the county. In 2002-2006 there were 334 deaths attributed to CRC in the county. When cancer deaths are viewed separately for males and females, however, CRC becomes the third leading cause of cancer death behind lung and breast cancers for females. Risk factors for CRC may include age, personal and family history of polyps or colorectal cancer, inflammatory bowel disease, inherited syndromes, physical inactivity (colon only), obesity, alcohol use, and a diet high in fat and low in fruits and vegetables. Detecting and removing precancerous colorectal polyps and detecting and treating the disease in its earliest stages will reduce deaths from CRC. (Healthy People 2010) Trends in colorectal cancer mortality from 1997 to 2006 show a gradual reduction with rates consistently below those for Upstate. The CRC average mortality rates for males in the county (27.2/100,000) and females (21.0/100,000) in 2001-2005 exceeded the HP2010 target of 13.9/100,000. Gender-specific rates in the county show a higher incidence and mortality rate for males than females, which is consistent with rates in NYS and the HVR. Incidence rates for both genders in the county are above those for NYS and the region. (Exhibits 1A.92,1A.91a-e). Prostate Cancer In the U.S., prostate cancer is the most commonly diagnosed form of cancer in males and the second leading cause of cancer death among males. It is most common in men aged 65 years and older, who account for approximately 80 percent of all cases. (Healthy People 2010) Prostate cancer incidence for Orange County males is slightly higher than those in the HVR and higher than those in NYS. Mortality rates in Orange County are higher than those in the HVR and NYS for the five year period 2001-2005. The prostate cancer mortality rate for Orange County males (27.3/100,000) met the HP2010 target of 28.8/100,000. In 2001-2005 there were 149 deaths attributed to prostate cancer in the county. (Exhibit 1A.92) Oral Cavity and Pharyngeal Cancer Alcohol and tobacco are the major risk factors for oropharnygeal cancer, and together explain 90 percent of these cancers. (Healthy People 2010) In the county, the incidence of oral and pharyngeal cancer in males is nearly three times that of females (males 12.7/100,000; females 4.6/100,000). The incidence rate for males and females is lower than that for the HVR and NYS, and shows improvement over the previous 5 year period. The mortality rate for oral and pharyngeal cancer in males is nearly double that for females in the county; the mortality rate for males is equivalent to that for HVR and slightly lower than that for NYS. The mortality rate in the county for females is above those for the region and the state. The mortality rate for males (3.2/100,000) exceeded the HP2010 target of 2.7/100,000; rates for females (1.7/100,000) met this target. In 2001-2005, there were 41 deaths attributed to oropharnygeal cancers in the county. (Exhibits 1A.92, 1A.91a-e). Thyroid Cancer The average incidence of thyroid cancer is higher in Orange County females than males, which is consistent with regional, state, and national data. The incidence rate in females (26/100,000) was over 3 times that of males (7.1/100,000). In 2001-2005, incidence rates for both males and females in the county were above HVR and NYS rates; rates for females were significantly above those for NYS. Mortality rates for both genders for 2001-2005 were comparable to the HVR and state. The causative agents of thyroid cancer are not well understood, and the potential contributors to increased incidence in county residents require further study. Other Chronic Conditions While heart disease, cancer and cerebrovascular disease account for the vast majority of deaths in the county, other chronic illnesses also result in significant death and disability. These include, in order of the number of deaths in county residents from 2005-2007: chronic lower pulmonary disease (443 deaths), diabetes (181 deaths), and cirrhosis (83 deaths). Other chronic illnesses, although not major causes of death, result in considerable disability in the population. These include such conditions as allergies and bronchitis, orthopedic deformities, arthritis, and hypertension. Hypertension and diabetes are also major contributing factors in the development of cardiovascular diseases. The proportion of heart disease deaths due to diabetes is projected to increase from 21 to 29 percent of the total over the first quarter of the 21st Century. (Healthy People 2010 Progress Review: Heart Disease and Stroke, April 2003) Orange County Community Health Assessment 2010-2013 Section I 22

Diabetes Certain racial and ethnic groups, including Black/African Americans, Latino/Hispanics, American Indians, and certain Pacific Islander and Asian American populations as well as economically disadvantaged and older people, are at higher risk for developing diabetes. In the U.S., diabetes-related mortality is reported to be 2 times higher in the African American population than in the White population. Both Type 1 and Type 2 diabetes have significant inherited components; overweight and obesity and lack of physical activity are strongly linked to the development of Type 2 diabetes. As shown in Figure 8, the mortality rate from diabetes in the county has fluctuated since 1997, with an upward trend since 2003. Within county comparisons by gender show that males had a higher mortality rate than females. Prevention Quality Indicators for diabetes-related hospital admissions show overall admission rates for county residents are below those expected; however they are 5% above those expected in Middletown residents, 21% above expected in Newburgh residents, and 41% above expected in Port Jervis residents. The 2004-2006 diabetes mortality rate (19.2/100,000) met the HP2010 target of 46/100,000. (Exhibits 1A.93, 1A.94) Figure 8 children. Asthma has been associated with exposure to allergens, indoor pollutants (for example, tobacco smoke), and ambient air pollutants (for example, ozone, sulfur dioxide, nitrogen dioxide, acid aerosols, and particulate matter). (Healthy People 2010). The mortality rate from asthma in the county has fluctuated, due to the relatively low number of events. The rate for 2004-2006 were higher than the HVR and well above the average for both Upstate and NYS. Hospital discharge rates for asthma in 2004-2006 (all ages) were above those for Upstate, the second highest in the HVR, and below those for NYS. For adults ages 25 and above, discharge rates were consistently higher than those for the region and Upstate, and were the highest in the HVR for adults ages 45 and over. Hospitalization rates for asthma in 2004-2006 exceeded HP2010 targets for all ages with the exception of ages 15-24. Asthma mortality rates in county residents from 2004-2006 were the highest in the HVR, and well above those for ROS and NYS. PQI Respiratory Indicators for hospital admissions were above that expected for residents in all three cities Middletown 40% above, Newburgh 15% above, and Port Jervis 75% above. (Exhibits 1A.83a-b, 1A.97a-b) Cirrhosis Sustained heavy alcohol consumption is the leading cause of cirrhosis, which is one of the 10 leading causes of death in the Orange County. Mortality rates varied from 2002-2006 in the county, with a slight increase in the rate from 2005-2006. Mortality rates and hospital discharge rates were higher in males than females in the county. (Exhibits 1A. 98a-b, 1A. 99) County mortality rates from cirrhosis were higher than those for the HVR and NYS and comparable to those for Upstate in 2004-2006. Mortality rates for cirrhosis in 2004-2006 in the county (7.1/100,000) exceeded the HP2010 target of 3.2/100,000. (www.health.state.ny.us/statistics) Source: NYSDOH, Community Health Data Set 2006 Respiratory Diseases Chronic Obstructive Pulmonary Disease/Chronic Lower Respiratory Disease (COPD/CLRD) occurs most often in older persons, and includes chronic bronchitis and emphysema. Approximately 80 to 90 percent of COPD is attributable to cigarette smoking. (Healthy People 2010). There has been a downward trend in the mortality rate in CLRD in the county since 2003, and the rate for 2004-2006 exceeded the Upstate rate and was well above the average for the HVR and state during this same time. The mortality rate for COPD/CLRD in the county was highest in persons ages 75 and over, and in males. Hospitalization rates in the county for COPD/CLRD in 2004-2006 show that females had higher discharge rates than males. County rates were higher than those for the HVR and slightly lower than those for NYS. (Exhibits 1A.95a-b, 1A.96) Asthma is a growing health problem in children and adults, with the highest rate of increase in preschool Orange County Community Health Assessment 2010-2013 Section I 23

SECTION ONE: POPULATIONS AT RISK B. ACCESS TO CARE 1. Availability and Utilization of Health Care Services Access to quality primary health care services is essential to maintain and improve health in the community. Access to primary care promotes persons having a consistent source of care where they receive preventive health education and health screenings, early detection and treatment of disease, and timely referrals for specialty care and other needed services. Ongoing contact with a primary health care provider is essential to prevention of complications and improved health outcomes. The New York State Department of Health Physician Profile (2009) reports that there are 624 physicians in Orange County, which represents a notable increase (42%) in the past five years. There are approximately 166 physicians per 100,000 population in the County, compared with 117 physicians per 100,000 residents in 2004. The number of primary care physicians in Orange County is estimated to be within the desired range of 60 to 80 per 100,000 recommended by the U.S. Department of Health and Human Services. Despite the sizable increase in Orange County physicians during the past five years, the number of primary care physicians has remained relatively constant. The NYSDOH Physician Profile database indicates that in 2009 there were approximately 60 primary care physicians (including internal medicine, family practice, OB/GYN) per 100,000 residents in the county. Nevertheless, problems in access to providers due to lack or limited insurance coverage, the geographic distribution of providers and language barriers in some communities in the county remain. Most Orange County physicians are in private solo or group practice. There is a growing trend toward large group practices in the county. The Crystal Run Health Care Group is the largest physician organization with over 150 physicians. Crystal Run Health Care is a rapidly growing multi-disciplinary group practice with 9 offices in Orange County and 2 in Sullivan County. The number of dentists in Orange County remained at a constant level during the past five years with 221 licensed dentists and 234 licensed hygienists in the county, a ratio of 1,707 residents per dentist. In addition to private physician offices, residents of the county are served by 6 hospital/medical centers (5 of which have primary care outpatient services) and 5 community health centers. The constellation of hospital services within the county is detailed in Exhibit 1B. Service statistics for inpatient and outpatient care in 2007 are provided in Exhibit 1B.2. Community Health Center services are summarized in Exhibit 1B.3. Some highlights include: Acute care and outpatient service needs of county residents are provided by 6 community hospitals affiliated with 3 independent health care networks Bon Secours Charity Health System (Bon Secours Community Hospital in Port Jervis and St. Anthony Community Hospital in Warwick), Orange Regional Medical Center (Goshen and Middletown Campuses), St. Luke s/cornwall Hospital (Cornwall and Newburgh Campuses). In addition, Keller Army Hospital serves West Point Academy staff, their families, and cadets. The 6 civilian hospitals are located in the county s 3 cities and in 3 other communities providing good geographic distribution of acute care services. In 2011, Orange Regional Medical Center (ORMC) will open the first new free-standing hospital in New York State in over 20 years. The 374 bed medical center in the town of Wallkill will be one of the largest medical centers between the Tappan Zee Bridge and Albany. ORMC has submitted a Certificate of Need application for a six bed neonatal intensive care unit. Ambulatory care services are provided at 5 hospital sites. One of these sites, the McAuley Primary Care Center in Port Jervis has historically provided primary care services to the uninsured and accepted payment based on a sliding fee scale, based on the Federally Qualified Health Centers (FQHC) model. There are 4 Federally Qualified Health Centers (Section 330), one migrant health center and one private health center serving the county, Hudson River Community Health Center in Walden, Hudson River Migrant Health Center in Goshen, Greater Hudson Valley Health Center in Newburgh and New Windsor, the Middletown Community Health Center in Middletown, Port Jervis, Montgomery, and Pine Bush, and the Ezras Choilim Health Care, Inc. located in the Hasidic community of Kiryas Joel. The services provided by each of these sites are summarized in Exhibit 1B.3. All provide general primary care services, including pediatric, adult, and prenatal care and have evening and/or weekend service hours. Hospital and CHC locations in the county are provided in Exhibit 1B.4. FQHCs are located in the designated medically underserved areas (MUA) of the county. Medically underserved areas are designated based on an Index of Medical Underservice which includes 4 variables: the percentage of the population below the poverty level, the percentage of the population ages 65 and over, the infant mortality rate, and the ratio of primary care physicians per 1,000 population. Designated MUAs in the county include: low income census tracts (1-6) in the city of Newburgh, the city of Middletown, the FCI in Otisville, the village of Kiryas Joel, and the south-central towns and villages with migrant farm workers. Orange County Community Health Assessment 2010-2013 Section I 24

There are no tertiary care centers located within the county. Many residents requiring tertiary care receive services at the region s tertiary care center at Westchester Medical Center located in Valhalla NY. This includes specialized perinatal, neonatal and pediatric services (Level III neonatal/pediatric intensive care), Cardiac, Cancer, and Level I Burn and Trauma Center Care. In addition, Orange County residents also obtain tertiary/specialized care at NYC hospitals and medical centers, New Jersey Medical Centers, as well as at Albany Medical Center and Vassar Brothers Medical Center. Orange County Hospitals/Medical Centers have affiliations with major medical centers in NYC or regional care networks for specialized care. In the spring and summer of 2009, the Orange County Department of Health s community health assessment process engaged key decision makers from hospitals, community health centers, health care providers, school and community leaders in a series of four Community Health Town Hall Meetings across the county to determine local health priorities and needs aligned with the 2008 NYS Prevention Agenda. This included in-depth discussions of the Community Health Assessment process, health status indicators, and the development of Community Service Plans (CSPs). Additionally, the county was part of a Hudson Valley Consortium (HEAL NY Phase 9 Assessment) which surveyed health care providers and consumers throughout the county. Key highlights from the Community Health Town Hall Meetings, Community Service Plans and the health care provider and consumer surveys related to access to care follow. (See Section IV Local Health Priorities for a more detailed discussion of the local health needs selection process.) Access to primary care for the uninsured and underinsured is a major concern especially with the downturn of the economy and the increasing unemployment rate resulting in greater numbers of county residents without health insurance. Lack of/inadequate medical and dental insurance coverage and high co-payments are major deterrents to obtaining both primary and specialty care in the county. CHCs and hospitals report recent increases in the uninsured population presenting for services. Health care providers report a shortage of behavioral/mental health and substance abuse treatment providers in the county, particularly pediatric providers. The availability of mental health inpatient services within the county has also diminished; St. Luke s Cornwall Hospital in Newburgh recently closed its inpatient mental health unit. There was concern that residents with a mental health hospitalization outside the county have a lack of continuity of care upon discharge. The loss of employment and subsequent loss of health and prescription drug coverage also negatively impact mental health. Difficulty in the recruitment of primary care and specialty physicians persists due to better reimbursement rates in NYC and neighboring states and more competitive salaries in nearby New York City. Recruitment of bilingual (Spanish-speaking) health professionals remains a challenge due to stiff competition within the NYC Metropolitan region Although Child Health Plus coverage has improved access to primary care for children and adolescents, Family Health Plus has not had the same impact for adults. This is in large part due to the fact that FHP income eligibility requirements are much more stringent (150% of the Federal Poverty Level - FPL) and undocumented residents are ineligible. The relatively low level of Medicaid reimbursement discourages existing private physician practices from accepting Medicaid patients and reduces the number they are able to accept due to the high cost of doing business, such as escalating malpractice insurance expenses, etc. Access to specialty care within the county is a universal problem for Medicaid, uninsured, and underinsured persons of all ages. Although the Community Health Centers are attempting to close this gap by bringing specialists on staff, there are both recruitment and funding limitations. Access to specialty care outside of the county is less than convenient medical transportation services for Medicaid recipients to the region s designated tertiary care center, Westchester Medical Center, are provided, however patients may experience unacceptable delays in scheduling appointments and must remain at the Center for the return bus trip, thus taking time away from work and school. As noted in Exhibit 1A.22, Medicaid transportation requests increased considerably from 2007-2008. Access to affordable preventive, restorative, and emergency dental services is a universal problem dental services are covered by some Child Health Plus plans, however they are not covered by Family Health Plus and Medicaid fee-for-service rates for restorative care are non-competitive. The NYSDOH Oral Health Surveillance, Oral Health Status of 3 rd Grade Children Survey reports that one-fourth of Orange County children do not have dental insurance coverage. Health access concerns expressed universally by hospital and health center representatives include: improving access to medical/dental care for the uninsured/underinsured, expanding transportation services, and increasing the availability of mental health, substance abuse, and specialty services for the uninsured, underinsured, and Medicaid patients. The total number of certified beds in the hospitals serving the county is 1,057. In 2008, these hospitals provided 218,864 patient days of service, 155,857 emergency room visits, and 1,122,723 outpatient visits. Community Health Center service data includes the services provided by the 5 FQHC sites. In 2008, the 4 Orange County Community Health Assessment 2010-2013 Section I 25

Community Health Center sites had a combined total of over 39,000 users (39,081). The effectiveness of the FQHCs in reaching high need populations is evidenced by the disproportionate share of low income, minority persons using center services compared to their general service areas. The majority of CHC/MHC patients are uninsured or Medicaid/MMC recipients. In 2008, an average of 39% of all CHC/MHC patients were enrolled in Medicaid or MMC, and a range of 27%-85% were uninsured; the highest percentage was among MHC users. Four Certified Home Health Agencies (CHHAs) provide home health services in Orange County; three of these agencies also provide Long Term Home Health Care Programs (Nursing Homes without Walls). (Exhibit 1B.5) The Orange County Health Department's Certified Home Health Agency and Long Term Home Health Care Programs provided 28,106 home health visits in 2008. Home health visits included public health nursing, physical, occupational and speech therapy, medical social work and nutritional counseling. The Orange County Department of Health CHHA provides home visits to residents recently discharged from the hospital, chronically ill adults and pregnant women and children. There are 10 skilled nursing facilities in Orange County, with a total of 1,618 beds (Exhibit 1B.6). In addition, there are 6 assisted living facilities in the county located in the communities of Middletown (2 facilities), Goshen, Tuxedo Park, New Windsor, and Warwick. The Prenatal Care Assistance Program (PCAP) service sites include the Hudson River Community Health and Middletown Community Health Centers. The Department of Health administers the WIC program in the county and service sites are located in Goshen, Middletown, Newburgh, Port Jervis, Warwick, Monroe, Walden, and Newburgh Free Academy and at the Migrant Health Center. In 2009, the OCDH provided supplemental food vouchers, nutritional counseling and breast-feeding support to 7,469 pregnant, postpartum, and breastfeeding women, infants, and children under the age of five. The Greater Hudson Valley Health Center in Newburgh is an additional provider of WIC services in the community. SECTION ONE: POPULATIONS AT RISK B. ACCESS TO CARE 2. Barriers to Health Care Access A. Financial Lack of health insurance coverage due to either lack of financial resources or employment benefits directly impacts access to care. In the county this is especially true for low wage earners, recent immigrants, migrant farm workers, and undocumented residents. Throughout NYS, low income children, adolescents, and pregnant women benefit from comprehensive health care coverage through PCAP and Child Health Plus, irrespective of their immigration status. The working poor often lack adequate health insurance and therefore access to care because their income is too high to qualify for Medicaid or Family Health Plus, and their employers are less likely to offer health insurance coverage. Even if health insurance coverage is available, it is often inadequate with high deductibles and co-payments for services. The physical and mental health impacts of the current economic recession cannot be overstated. George Washington University s Rapid Public Health Response Project cites survey findings that a rising percentage of Americans are failing to obtain needed health care and cutting back on prescribed medications. Researchers also predict that every 1 percent rise in unemployment will result in around 1 million additional Americans becoming uninsured. (U.S. Economic Crisis Having Worrisome Effect on Health, The Nations Health, March 2009 @ www.thenationshealth.org) Studies have historically found that immigrants are less likely to be insured than are native-born Americans, and have reported significant differences in the immigrant population based on legal status. The Los Angeles Family and Neighborhood Survey of 2000-2001 found that 69% of undocumented residents at the time of interview were uninsured, compared with 37% of legal residents, 22% of naturalized citizens and 17% of U.S. native-born residents. ( Immigration Status and Health Insurance Coverage: Who Gains? Who Loses? American Journal of Public Health, January 2005) Although Orange County residents benefit from a good supply of medical providers, many do not accept Medicaid patients. As of December 2007, 49,533 persons in the County were eligible for Medicaid, of whom 23,897 (48%) were children. (NYSDOH December 2007 Medicaid Eligibility Report) According to information from the NYSDOH Community Health Data Set, 37.9% of the women in Orange County who gave birth in 2004-2006 had Medicaid or were self pay (uninsured) compared with 31.7% for ROS. There are a total of 14 Managed Care Plans available in Orange County: 10 Commercial, 5 Medicaid Managed Care (MMC), 7 Child Health Plus (CHP), and 5 Family Health Plus (FHP). (Exhibit 1B.7). In March 2007, enrollment in Medicaid Managed Care became mandatory in Orange County for Medicaid recipients. As of February 2009, 31,515 Orange County residents were enrolled in MMC (84% of those eligible). The primary MMC providers in Orange County are Affinity Health Plan and NYS Catholic Health Plan. (Recipients Eligible for and Enrolled in Medicaid Mainstream Managed Care by County, Plan, and AID Category, February 2009 @ www.health.state.ny.us/health_care /medicaid/statistics) Orange County Community Health Assessment 2010-2013 Section I 26

As of February 2009, there were 9,406 children residing in the county enrolled in Child Health Plus; 3,769 county residents were enrolled in Family Health Plus. (Family Health Plus Enrollment by County, Plan, and AID Category, February 2009@ www.health.state.ny.us/health_care). Community Health Centers report an increase in Child Health Plus enrollment; however the extent of coverage by Family Health Plus is less because of more stringent income requirements and citizenship/immigration status eligibility requirements. Access to care is promoted through facilitated enrollment assistance for the uninsured at multiple public health and community health care sites for individuals and families for Medicaid, Child Health Plus A and B, Family Health Plus, WIC, and PCAP. This enrollment process involves use of a single application for all programs. Access to care for persons enrolled in managed care is evaluated as a component of the NYSDOH Managed Care Plan Performance process and is reported annually. The NYSDOH eqarr system was developed to enable consumers to give direct input in the evaluation of the quality of managed care, including access and service measures. Access and service measures evaluated by consumers include: children s access to primary care practitioners, adult access to preventive care services, problems encountered in obtaining care, problems with services received, and the timeliness in receiving services. According to the 2008 NYSDOH Managed Care Plan Performance Report for Commercial and Medicaid Health Plans, average ratings for access measures (i.e., getting care needed and receiving services quickly) were lower for Medicaid Health Plans than Commercial Health Plans. Several Medicaid Health Plans serving the HVR scored significantly higher than the statewide average in one or more access measures. There was considerable variability in the performance ratings by Plan for both Medicaid and Commercial Health Plans in the region. The Expanded Risk Factor Surveillance System (EBRFSS) augments the CDC Behavioral Risk Factor Surveillance System (BFRSS) conducted each year in NYS. EBRFSS is a random digit dialed telephone survey of the noninstitutionalized adult (ages 18 and over) population in the state. The purpose of this survey is to collect uniform, county-specific data on preventive health practices and risk behaviors that are linked to chronic diseases, injuries, and preventable infectious diseases. In 2003, the first EBRFSS was conducted in 38 counties and county groupings across the state. One of the core areas assessed was Core 2 Health Care Access (Exhibit 1 B.8). This included questions regarding health insurance coverage and as proxies for preventive and primary care access, queries as to having a routine physical in the past 2 years, and any occasions of needing health care and not being able to obtain it in the past 12 months. In 2008-2009, a second EBRFSS was conducted in all 57 Upstate NY counties; New York City was surveyed as one area. Interim six-month data for 2008 related to access to care are included in the following 2003 fullyear highlights for Orange County. These data are considered provisional due to small sample size. Overall 19.2% of Orange County respondents 18-64 years of age were uninsured, males were more likely to be uninsured than females (22.7% vs. 15.6%), as were younger adults (ages 18-34 31.7%). The uninsured rate for the state as a whole was 17%. EBRFSS interim data for 2008 suggest a decline in the percentage of uninsured adults. Persons with a high school education or less were more than twice as likely to be uninsured than were persons with more than a high school education (29% vs. 12.5%). 11% of respondents reported not having a routine physical in the past 2 years, which is consistent with results for the region and the state as a whole. 2008 provisional data indicate a slight increase for this indicator. 7.9% of Orange County respondents reported being unable to obtain medical care in the past 12 months when they needed it, compared with 6.6% for the region and 7.6% for NYS, differences that were not statistically significant. Statewide data from the 2003 survey provide additional insight on barriers to health care access based on age, gender, income and ethnicity/race, as the larger sample size permits more detailed analysis, although the results are not directly applicable to Orange County. Persons in NYS who were Hispanic/Latino were most likely to be uninsured (36.8%), compared with Black/African Americans with 20% and Whites with 9.8%. Insurance status was inversely related to income, with persons with lower income levels (household incomes of < $24,999) most likely to be uninsured. Adult males were twice as likely to report not having a routine physical in the past 2 years than were females (14.8 vs. 7.3%). Females were more likely than males to need medical care and not be able to obtain it, as were adults ages 18-34, Hispanic/Latinos, persons with lower educational attainment and household incomes (all of these except females were also more likely to be uninsured). B. Structural Access to medical care might be enhanced by improved public transportation in Orange County. Persons without an automobile may have difficulty accessing medical services, and face lengthy travel times and multiple transfers to reach health care. To offset this barrier, all Community Health Centers and Health Department clinics are located in areas of high need. Hospitals and medical centers are distributed throughout the county, however some are not located in low income areas or along public transportation routes. Many individuals and families need to travel out of county for specialty care and with the exception of Medicaid-funded transportation, public transportation is not easily accessible. Working parents Orange County Community Health Assessment 2010-2013 Section I 27

are often unable to afford or obtain time off from work to attend appointments during the day, and child care needs impede out of county travel. Increasing service demands by the uninsured, and the complex health and social needs with which they present stress the capacity of providers and health centers to assure timely, comprehensive care. C. Personal Orange County has a large number of recent immigrants, both documented and undocumented. These individuals need linguistically and culturally appropriate outreach, engagement, and care services. The importance of preventive care is not well understood or accepted in some cultural groups and there is often hesitancy to use government programs. Many undocumented immigrants perceive that accessing health care places them at risk of deportation or works against their immigration application. Undocumented pregnant women and children legally have access to medical care in New York State through PCAP and Child Health Plus as do all persons in need of emergency hospitalization. Out of necessity, obtaining primary and preventive health care often becomes a lower priority for low income persons than meeting basic survival needs (work, food, and shelter). Illiteracy in English as well as in native languages is another personal barrier to accessing care. Outreach has to involve the use of indigenous community workers and trusted community leaders to reach persons for whom print information is ineffective. Orange County was a site for the Immigrant Health Study The Health of Recent Immigrants to the Lower Hudson Valley and the Challenges Faced by Those Who Serve Them. This study was conducted by researchers from the New York Medical College School of Public Health (NYMC-SPH) in partnership with the Hudson Valley Regional Health Officers Network (HVRHON). The study purpose was to better understand the health issues and barriers facing recent immigrants to the LHV and the challenges faces by the health providers serving them. The project included a community needs assessment in 12 target communities with large concentrations of recent immigrants. The target community within the county selected for study was the city of Newburgh. During the period 1990-2000, approximately 9,000 immigrants established residence in Orange County, with over one-third known to have settled in the city of Newburgh (Census 2000). The community needs assessment phase of the project included interviews with three groups of individuals: 1) providers who serve recent immigrants, 2) key informants (individuals who interact with or have knowledge of immigrants and their health issues but do not provide direct clinical services), and 3) recent immigrants. Interviews with providers and key informants were conducted by phone; interviews with recent immigrants were conducted in person. A range of 6-19 providers and key informants were interviewed and 6 recent immigrants per target community. Due to the limited number of survey participants, results should be interpreted with caution. Immigrants who participated in the study were predominantly adult Hispanic/Latina females, under 40 years of age, with limited English proficiency, and residency in the U.S. of 5 years. The report cites Census estimates that Orange County has experienced a 28% increase in foreign-born population from 2000-2005 compared with 16.3% nation wide. Growth in the county s foreignborn population was 31.6% from 1990-2000. (Exhibit 1A.14b) Key study findings for the LHV region include: A much higher percentage of providers than key informants indicated that the overall health and language needs of the immigrant population were being met in the target communities. Providers most frequently cited insufficient services for referral for mental health, dental, and legal issues. Providers/key informants identified housing, employment, finances and health insurance as key concerns in recent immigrants. Providers/key informants identified depression and alcoholism as common health issues in recent immigrants as did study immigrants. Only 50% of study participants had a regular provider and 73% had used a hospital ED in the past year. 50-75% of study immigrants reported their health providers spoke their language little or not at all. 52.7% of study immigrants had insurance for themselves or a family member; 10.8% had no insurance for anyone in the family. Complementary and Alternative Medicine (CAM) use was prevalent and study immigrants expressed a lack of comfort in discussing this with their health care providers. Two out of five study immigrants reported a health problem and more than one-third rated their health as fair or poor. 25% of study immigrants reported chronic diseases, 20% infectious diseases (primarily TB), and 10% mental health issues. 40% of study immigrants reported their partners (mostly males) had never been to a doctor for a check-up. Almost half of study immigrants reported going to the doctor only when they were ill. Over 90% of study immigrants found it difficult for immigrants to live in their community. Orange County Community Health Assessment 2010-2013 Section I 28

SECTION ONE: POPULATIONS AT RISK C. BEHAVIORAL RISK FACTORS The leading underlying causes of death in Orange County involve behavioral risk factors. These are external contributing factors that result in the disease condition or injury which is the primary cause of death. Many external factors - use of tobacco; alcohol and substance abuse; diet and activity patterns; risky sexual behavior; lack of use of primary and preventive care services; unsafe use of motor vehicles and firearms for example - contribute greatly to the leading causes of death in the county. Individual behaviors and environmental factors account for about 70% of premature deaths in the U.S.; preventive interventions that address these contributing factors can be expected to reduce the incidence and prevalence of disease, enhance the quality of life, and increase longevity. (Healthy People 2010: A Systematic Approach to Health Improvement @ www.healthypeople.gov). As reviewed in Section I A.2 Overall Mortality and Leading Causes of Death, the leading causes of death are best evaluated based on the total number of deaths, age- and sex-adjusted mortality rates. Analysis of the impact of underlying causes of death to primary causes of death is critical to intervention efforts. Interventions targeting the underlying causes of death such as tobacco and alcohol attributable deaths, obesity and diabetes-related deaths, are vital to improving the overall health status of county residents. Prevention efforts to encourage adoption of health promoting behaviors are key to disease risk reduction. The Expanded Risk Factor Surveillance System (EBRFSS) augments the CDC Behavioral Risk Factor Surveillance System (BFRSS) conducted each year in NYS. The most recent full-year EBRFSS survey for which comparative data are available was conducted from July 2002 July 2003 across NYS and reported for 38 localities (individual counties or groups of counties), one of which was Orange County. Adult residents in all localities were surveyed using EBRFSS questions relating to 16 core behavioral risk areas: health status/healthy days, health care access, exercise, diabetes, asthma, arthritis, tobacco use, tobacco environmental tobacco smoke (ETS), alcohol consumption, weight status, mammography, sexual behavior, family planning, cardiovascular disease, prostate cancer screening, and colorectal cancer screening. In addition, localities across the state selected optional risk area modules to be surveyed. For Orange County, these included: cholesterol awareness, disability, fruit and vegetable consumption, hypertension awareness, injury control falls, immunization, oral health, weight control, and cervical cancer. As the core areas were identical for all localities, Orange County results can be compared with results for NYS and the Hudson Valley Region (HVR). For optional modules, comparisons can be made only for counties surveyed for that specific module comparisons to the HVR and NYS are not possible. Comparative results for the core behavioral risk areas in the 2003 EBRFSS are presented in Exhibit 1C.1; optional behavioral risk areas are presented in Exhibit 1C.2. The 2008 NYS EBRFSS now includes 58 areas, including all 57 NYS counties outside of New York City; New York City is surveyed as a single area. For each area, the goal is to complete about 650 interviews using a standardized questionnaire. Interim, six-month data results for Orange County collected from July 1- December 31, 2008 are included in the following discussion. It is important to note that these estimates are based on a much smaller sample size than those in the full survey, which results in very wide confidence intervals. These data are provided for descriptive purposes only, and should be interpreted with caution as provisional data, pending more reliable analysis of full-year data. Orange County Community Health Assessment 2010-2013 Section I 29

Core Area Figure 9 - Core Behavioral Risk Factors Overview Indicator OC EBRFSS Data (2003) Statistically Different than other HVR Counties (2003) Statistically Different than NYS (2003) OC Six-Month Interim EBRFSS Data (2008) HP 2010/NYS PA 2013 Targets Core I: Health Status/Healthy Days 1a. Self Rated Health Status (good-excellent) 1b. Physical Distress Days (<14 days in past month) 1c. Mental Distress Days (<14 days in past month) 86.4% 89.7% 89.3% No No No No No No 86.2% 91.9% 90.1% 90% 1996 U.S. Baseline n/a n/a Core 2: Health Care Access 2a. Health Insurance 18-64 2b. Health Insurance 18+ 2c. Routine Physical < 2 years 2d. Unable to access medical care < past 12 months 80.8% 83.5% 89.0% 7.9% No No No No No No No No 87.2% 88.9% 87.0% 100% 100% n/a 7% Core 3: Exercise 3a. No leisure-time physical activity/exercise in past 30 days 26.5% No No 23.9% < 20% Core 4: Diabetes Core 5: Asthma 4a. MD diagnosed Diabetes 6.1% No No 6.8% 2.5% 25 cases/ 1,000 5.7% (PA) 5a. Lifetime Asthma diagnosed by 13.5% No No 19.6% n/a a medical professional 5b. Current Asthma diagnosed by a medical professional 9.0% No No 12.9% n/a Core 6: Arthritis 6a. Arthritis diagnosed by a medical professional 6b. Adults with MD diagnosed Arthritis or Possible Arthritis (CJS only). 23.2% 23.4% No No No No 24.7% n/a n/a Core 7: Tobacco Use 7a. Ever smoked 100 cigarettes in your lifetime 7b. Current Smoker 7c. Attempted to Quit Current Smokers 7d. Attempted to Quit Everyday Smokers 7e. Status of cigarette smoking 7e1. Everyday smoker 7e2. Someday smoker 7e3. Former/Never Smoked 51.1% 24.3% 63.3% 58.7% 18.2% 6.1% 75.7% No Yes Higher than Rockland No No Yes Yes Yes No No No No No No No 17.2% 8.9% n/a 12% 75% 75% 12% 12% 88% Everyday/some day smoker rates higher than Rockland/ Westchester and lower for former/never Core 8: Tobacco ETS 8a. Home Smoking Policies 8a1. Not allowed 8a2. Allowed some places 8a3. Allowed anywhere 8b. Home Smoking (No) 69.8% 10.4% 19.8% 77.4% No No No No No No No No 84.2% 90% n/a n/a n/a Core 9: Alcohol Consumption 9a. At risk for binge drinking 9b. At risk for heavy drinking 12.8% 3.9% No No No No 18.7% 3.4% 13.4% > 50 % meet guidelines for low risk drinking Orange County Community Health Assessment 2010-2013 Section I 30

Core Area Indicator OC EBRFSS Data (2003) Statistically Different than other HVR Counties (2003) Statistically Different than NYS (2003) OC Six-Month Interim EBRFSS Data (2008) HP 2010/NYS PA 2013 Targets Core 10: Weight Status 10a. Overweight or Obese (BMI > 25) 10b. Weight Status 10b1. Underweight/Normal (BMI < 25) 10b2. Overweight (BMI 25-29) 60.4% 39.6% 39.0% No No No No No No 64.3% 40.9% n/a 60% Healthy Weight - BMI 18.5 to 25 10b3. Obese (BMI 30+) 21.4% No No 23.4% 15% Core 11: Mammography 11a. Ever had mammography (women, 40+) 11b. Received mammography screening in past 2 years (women, 40+) 11c. Why received mammography screening 11c.1 Routine checkup 11c.2 Breast Problem 11c.3 Had Breast Cancer 86.2% 73.8% 91.2% 4.9% 3.9% No No No No No No No No No No 91.2% 79.0% n/a 70% n/a n/a n/a Core 12: Sexual Behavior 12a. Ever counseled by medical professional on STD prevention/condom use (<64) 12b. Sexually Active (18-64) 12c. Used condom last sexual intercourse (< 64) 12d. Multiple partners in past 12 months (sexually active < 64) 13.4% 88.5% 21.0% 6.1% No No No No Yes OC rate lower Yes OC rate higher Yes OC rate lower No n/a n/a 50% n/a Core 13: Family Planning 13a. BC use to prevent pregnancy by men (18-59) and women (18-44) 13a1. Use BC 13a2. No BC - at risk 13a3. No BC 69.5% 15.6% 14.8% No No No No No No n/a 0% n/a Core 14: Cardiovascular Disease 14a. MD diagnosed heart attack, angina, or stroke 14b. MD diagnosed CHD (Heart Attack or Angina) 7.1% 6.2% No No No No 3.6% 3.5% n/a n/a Core 15: Prostate Cancer/ Screening 15a. Ever had PSA test (men 40+) 15b. Ever had digital rectal exam (men 40+) 15c. PSA test in past 2 years (men 40+) 15d. Ever told by medical professional had prostate cancer (men 40+) 61.5% 78.6% 53.4% 2.9% No No No No No No No No 73.0% 70.0% 68.1% 8.5% n/a n/a n/a n/a Core 16: Colorectal Cancer Screening 16a. Ever used BST at home (50+) 16b. Used BST at home in past year (50+) 16c. Used BST at home in past 2 years (50+) 16d. Used BST at home in past year or had lower endoscopy in past 10 years (50+) 16e. Ever had sigmoidoscopy or colonoscopy (50+) 16f. Had sigmoidoscopy or colonoscopy in past 10 years (50+) 42.6% 17.5% 26.7% 54.6% 52.3% 50.2% No No No No No No No No No No No No 31.1% 7.9% 10.8% 74.8% 73.9% 73.5% n/a n/a 33% n/a 50% n/a Healthy People 2010 and NYS Prevention Agenda 2013 Targets. 2008 BRFSS provisional data suggest statistically significant differences in comparison to 2003 full-year data. Orange County Community Health Assessment 2010-2013 Section I 31

Core Behavioral Risk Factors The discussion of behavioral risks in each core area based on the full year 2003 EBRFSS follows. Provisional six-month EBRFSS data is included as indicated. Core I: Health Status/Healthy Days This section included (3) areas of inquiry: self-rated health status, reported number of physical distress days in the past month, and reported number of mental distress days in the past month. These are indicators of perceived health and represent a qualitative assessment of health status by the individual. Results for Orange County were slightly below baseline values for the U.S., and were consistent with those for the HVR and NYS. Orange County residents who were older (> 55 years of age) and who had less education (< high school) were more likely to report fair to poor health status, however differences in physical and mental distress days did not vary significantly by age or education. Statewide data, although not directly applicable to the population of Orange County, lend additional insight based on findings by race/ethnicity and income. Persons who were Black or Hispanic and those who were low income were more likely to report poor to fair health status. Income was inversely related to the number of physical and mental distress days experienced in the past month, with low income individuals reporting a higher number of both. Core 2: Health Care Access This section included (4) areas of inquiry: health insurance coverage for persons 18-64 years of age, health insurance coverage for persons ages 18 and over (inclusive of persons 65 and over, the majority of whom should be eligible for Medicare benefits), having had a routine physical exam in the past two years, and any time in the past 12 months when needed medical care but could not obtain it. These results are reviewed in detail in Section 1B. Health Care Access for Orange County, the HVR, and NYS. In 2003, 80.8% of Orange County adults ages 18-64 reported having health insurance coverage (HP 2010 goal is 100%) and the percentage of adults needing medical care but who were unable to obtain care (7.9%) was slightly above the HP 2010 target of 7 percent. Provisional results from the 2008 EBRFSS survey suggest that 87.2% of adults ages 18-64 reported health insurance coverage. In addition an estimated 11% of those surveyed indicated they needed to see a doctor in the past year but were unable to because of the cost. Core 3: Exercise This section included (1) area of inquiry: whether the individual had participated in leisure-time physical activity or exercise during the past 30 days. The HP2010 target is to reduce the number of adults that do not engage in leisure time physical activity to 20 percent. Regular physical activity is essential for achieving and maintaining a healthy weight and for mental health and stress reduction. Exercise decreases the risk of death from heart disease, and of developing diabetes and colon cancer. It also reduces the complications of chronic diseases such as diabetes, hypertension, and heart disease. Physical activity is associated with lower death rates overall in adults, even at moderate levels. (Healthy People 2010) On average, Orange County adults did not achieve the HP 2010 target and residents with a high school education or less engaged in leisure time physical activity the least. Statewide, this same trend was found for education. Persons ages 65 and over were also less likely to be physically active. In addition, NYS residents who were Hispanic/Latino were the least likely to have engaged in physical activity in the past month (38.7%), followed by Blacks/African Americans (29.9%). Not participating in leisure time physical activity correlated closely with income, with persons in the lower income brackets (< $24,999) reporting the higher rates of physical inactivity compared with those in the higher income brackets (> $25,000). This question did not address the level of physical activity during work hours (e.g., laborer vs. office work). Provisional data from the 2008 EBRFSS indicate that the HP 2010 target for physical activity/exercise has not yet been met. Core 4: Diabetes This section included (1) area of inquiry: whether the person had physician-diagnosed diabetes. The incidence of diabetes, especially Type 2 diabetes is increasing in the United States. The number of persons diagnosed with diabetes has increased steadily over the past decade; however many still remain undiagnosed. This increase in the frequency of diabetes has occurred disproportionately in certain minorities and in low income groups. Over the past decade, diabetes has remained the seventh leading cause of death in the United States, and is the leading cause of nontraumatic amputations, blindness, and end-stage renal disease (ESRD). (Healthy People 2010) Behavioral risk factors such as poor food choices, lack of physical activity and the resultant obesity as well as the aging of the at-risk population all contribute to the growth in diabetes incidence and prevalence. The rate of physiciandiagnosed diabetes in Orange County adults is above the HP 2010 target for the general population as are the rates for some of the contributing factors in diabetes, such as levels of obesity and lack of physical activity. As noted in Section 1A Chronic Disease, diabetes incidence and complication rates remain above HP 2010 targets. Not surprisingly, in the 2003 EBRFSS, older persons (ages 55 and above) were more likely to be diagnosed with diabetes by a medical professional (16.6%). Differences based on educational level were not significant for Orange County residents. Statewide data show a consistent trend of increased rates of diagnosis with increasing age, which is expected due to the association of the most common form of diabetes (Type 2) with advancing age. Black/African American NYS residents were more likely to be diagnosed with diabetes than were Whites or Hispanic/Latinos as were persons with lower educational attainment and incomes. Provisional data from the 2008 EBRFSS indicate that diabetes prevalence remains above HP 2010/PA 2013 Targets. Core 5: Asthma This section included (2) areas of inquiry: lifetime asthma and current asthma diagnosed by a medical Orange County Community Health Assessment 2010-2013 Section I 32

professional. The incidence and prevalence of asthma have been increasing in both children and adults in New York and in the nation. Asthma is now the most common chronic disease of childhood. (Healthy People 2010, NYSDOH - Asthma Among Adults in New York State, 1996-2002: Prevalence and Health Behavior) As stated in Healthy People 2010, Socioeconomic status, particularly poverty, appears to be an important contributing factor to asthma illness, disability, and death. In the United States, the rate of asthma cases for nonwhites is only slightly higher than for Whites, yet the death, hospitalization, and ED-visit rates for nonwhites are more than twice those for Whites. Although reasons for these differences are unclear, they likely result from multiple factors: high levels of exposure to environmental tobacco smoke, pollutants, and environmental allergens (for example, house dust mites, cockroach particles, cat and dog dander, and possibly rodent dander and mold); a lack of access to quality medical care; and a lack of financial resources and social support to manage the disease effectively on a long-term basis. The true prevalence of asthma in Orange County residents may be underestimated in the EBRFSS results, as this only assessed cases diagnosed by a medical professional and relies on accurate recall by the respondent. In 2003, the prevalence of asthma in the adult population in Orange County did not differ significantly from that in the HVR or NYS, and no significant differences were observed due to age, gender, or education. Provisional data from the 2008 EBRFSS suggest an increase in asthma prevalence in the county. Statewide data from the 2003 survey show increased prevalence in adult females and in adults in the lowest income bracket (< $10,000). Direct measure of asthma rates in children in Orange County are unavailable at this time, however indications of the extent of disease severity and the effectiveness of primary care treatment for asthma can be drawn from hospital discharge rates for this diagnosis. SPARCS data for 2004-2006 indicate that the hospitalization discharge rate due to asthma in Orange County children (under the age of 5 and ages 5-14) is the second highest in the HVR. Although county rates are well below NYS averages for these two age groups, the reasons for this elevated rate require further analysis. The statewide BRFSS also studied trends in health risk behavior in adults with asthma from 1996-2002, and the results showed that adults with asthma were as likely to smoke, report less physical activity, and were more likely to be obese than adults without asthma all health behaviors that exacerbate disease symptoms. (NYSDOH - Asthma Among Adults in New York State, 1996-2002: Prevalence and Health Behavior) Core 6: Arthritis Arthritis is one of the most common chronic conditions in the United States and is the leading cause of disability in adults. Arthritis often limits daily activities and follows only heart disease as a cause of work disability. (Healthy People 2010). The impact of arthritis to the health of Orange County residents is likely to increase, as the number of older persons continues to grow. In 2003, the prevalence of arthritis in county adults was consistent with that found in the HVR and NYS females were more likely to be diagnosed (also related to increased lifespan), as were persons with lower educational attainment. For the state as a whole, White adults were most likely to have been diagnosed with this condition. Provisional data from 2008 EBRFSS for arthritis prevalence appear comparable to 2003. Core 7: Tobacco Use & Core 8: Tobacco ETS The health risks from smoking and exposure to environmental tobacco smoke (ETS) are well established. Cigarette smoking is the most preventable cause of death in Orange County. As so adeptly stated in Healthy People 2010, smoking results in more deaths each year in the United States than AIDS, alcohol, cocaine, heroin, homicide, suicide, motor vehicle crashes, and fires - combined. Smoking is a major risk factor for heart disease, stroke, lung cancer, and chronic lung diseases - all leading causes of death in the U.S. Smoking during pregnancy can result in miscarriages, premature delivery, and sudden infant death syndrome. ETS increases the risk of heart disease and chronic lung conditions, including asthma and bronchitis in children. ETS is responsible for an estimated 3,000 lung cancer deaths each year in the U.S. among non-smoking adults. According to the American Cancer Society, cigarette smoking is responsible for 80% of lung cancers, and for at least 30% of all other cancer deaths. Lung cancer remains the leading cause of death for males and females in the county. Stopping smoking substantially decreases the risk of cancer and cardiovascular disease and increases longevity. The EBRFSS included five questions regarding past and current smoking behaviors: ever smoked 100 cigarettes, current smoker, attempted to quit (current smokers), attempted to quit (everyday smokers), and status of cigarette smoking (everyday smoker, someday smoker, or former smoker). The findings for Orange County adults were generally consistent with those found in the state and for the HVR. The exceptions were significantly higher rates for current smoking in Orange County than in Rockland County and higher rates of everyday/someday smoking in Orange than in Rockland and Westchester Counties (and correspondingly lower rates for former/never). Smoking rates in adults in Orange County are high at 24.3%, when compared with the HP 2010/PA 2013 target of 12%. The percentage of adults who are attempting to quit smoking are also below HP2010 targets. National data indicate smoking prevalence among U.S. adults has declined from 24% in 1998 to 21% in 2006 (Healthy People 2010 Progress Review, Tobacco Use, August 2008 @ www.healthypeople.gov). The 2008 EBRFSS provisional findings suggest a significant decline in the percentage of Orange County adults who smoke everyday and an increase in those who do not permit smoking in their homes. Orange County Community Health Assessment 2010-2013 Section I 33

The prevention of tobacco use among children and adolescents is especially critical as more than 90% of smokers begin to smoke before age 20. The Expanded BRFSS surveys adults ages 18 and over, and therefore the results are not applicable to youth. Trends in cigarette use by youth in New York State are assessed by the biennial Youth Tobacco Survey (YTS). Respondents include youth in grades 6-12 enrolled in public and private schools. Although the results are not directly applicable to Orange County youth, insight can still be gained by analysis of trends for the state as a whole. Findings from this survey are encouraging as they show significant reduction in current cigarette use by high school and middle school students in NYS and ROS from 2000 to 2006. These reductions are due in part to social regulation regarding the sale of tobacco products to minors and indoor air policies, the increasing cost of cigarettes, and comprehensive Tobacco Control Program initiatives in NYS. As shown in Figure 10, rates for current use of cigarettes in high school students in the ROS declined to 17.2% in 2006 from 33.5% in 2000; the decline in middle school students was from 12.0% to 3.8%. The HP2010 target for adolescents currently smoking is 16% or less. Figure 10 Smoking during pregnancy carries significant health risks for the developing fetus, and is a major contributor to both low birth weight and spontaneous abortion. The health of infants continues to be further compromised by exposure to second hand smoke after birth. The HP2010 target is that 99% of pregnant women abstain from smoking during pregnancy; data on trends for pregnant women in NYS presented below indicate that additional intervention is needed to reduce smoking by pregnant women. Figure 11 Core 9: Alcohol Consumption Excessive drinking negatively impacts health. Longterm heavy drinking increases risk for high blood pressure, heart rhythm irregularities (arrhythmias), heart muscle disorders (cardiomyopathy), stroke, and certain types of cancer, especially of the esophagus, mouth, throat, and larynx. Heavy alcohol use also increases chances of developing cirrhosis and other liver disorders. Women s risk of developing breast cancer increases slightly if they drink two or more drinks per day. Complete abstinence from alcohol is recommended during pregnancy - heavy alcohol use is associated with the development of fetal alcohol syndrome (FAS) in infants and even moderate intake has demonstrated effects on preterm delivery. Interestingly, recent studies have shown a protective effect of light-to-moderate drinking (1 or 2 drinks a day) on heart health, particularly among those at greatest risk for heart attacks, such as men over age 45 years and women after menopause. Health authorities do not however advocate initiating drinking for those who abstain from alcohol, due to its substantial adverse health effects in persons who are at risk for becoming alcohol dependent. Alcohol use is also implicated in a substantial proportion of injuries and deaths from motor vehicle crashes, falls, fires, and drownings. It also contributes to homicide, suicide, marital violence, and child abuse and is associated with risky sexual behavior. (Healthy People 2010) In 2003, nearly 13% of adults in Orange County reported being at risk for binge drinking (drank in past month and had 5 or more drinks per drink occasion), which met the Healthy People 2010 target of 13.4%. However only 3.9% of county residents reported heavy drinking (defined as more than 2 drinks per day for males and 1 drink per day for females in the past month). The findings for both of these indicators for Orange County were consistent with the HVR and NYS. Statewide, males were 5 times more likely to report binge drinking than were females. Whites and younger adults were most likely to engage in binge drinking, however no significant differences were found by income or educational level. Trends in binge drinking Orange County Community Health Assessment 2010-2013 Section I 34

among NYS adults from 1995-2003 are indicated below. Provisional data for 2008 indicate that rates of binge drinking in county adults remain above HP 2010 targets. Figure 12 Alcohol is the most common drug used by adolescents aged 12 to 17 years. Early age of onset of drinking is a strong predictor of later alcohol dependence. Adolescents who delay drinking until the age of 21 or later only have a 10% chance of developing alcohol dependence at some point in their lives compared with a 40% chance for those who begin drinking at age 14 or younger. (Healthy People 2010) Trends in binge drinking in NYS high school students from 1997-2003 show a higher rate for upstate counties, however there appears to be an overall downward trend in binge drinking for upstate counties. Figure 13 Although alcohol use in adolescents in Orange County was not measured directly, selected indicators show a negative trend in alcohol-related incidents involving adolescents. According to the Kids Well-Being Indicators Clearinghouse database, from 2003 to 2007 the rate of driving while intoxicated arrests in Orange County youth ages 16-21 years increased from 75.6 to 79.7 (per 10,000); rates for ROS were 66.6 in 2003 and 65.9 in 2007 respectively. It should be noted that this may in part reflect enhanced surveillance and enforcement efforts related to underage drinking and driving. The rate of arrest for Drug Use/Possession/Sale/DUI declined in 2007 to 107.4; the rate for ROS in 2007 was 91.7 The admissions rate for alcoholism and substance abuse in 2001 for residents of all ages in Orange County was 165 per 10,000 residents compared with 168.6 for NYC and 138.4 for the ROS. Persons under 18 comprised 8.6% of alcohol and substance abuse treatment admissions for county residents, compared with 5.1% for NYS and 7.3% for ROS. (NYS OASAS @ www.oasas.state.ny.us) There has been an upward trend in the drug-related hospitalization rate in county residents from 1997-2006; the rate for 2004-2006 was consistent with that for the HVR, above that for ROS, and below those for NYS. (Community Health Data Set) Core 10: Weight Status Overweight and obesity contribute greatly to many preventable causes of death. Generally, higher body weights are associated with increased mortality. The number of overweight children, adolescents, and adults has risen in the U.S. over the past four decades. Overweight and obesity increase risk of many conditions including high blood pressure, high cholesterol, Type 2 diabetes, heart disease and stroke, gallbladder disease, arthritis, sleep disturbances, and certain types of cancers. (Healthy People 2010) The majority of adults in the United States are now estimated to be overweight or obese. The proportion of adults ages 20 and over who were at a healthy weight (BMI 18.5-25.0) decreased from 42% in 1988-1994 to 32% in 2003-2006. The proportion of adults ages 20 and older who are obese (BMI 30+) increased from 23% to 33% during this same time period, more than double the HP2010 target of 15%. Obesity is especially common among low income women, and is more common among Black/African American and Mexican American women than among White women. There are also gender differences in the prevalence of obesity in certain ethnic and racial groups the proportion of women who are obese is higher than the proportion of men who are obese in both Black/African Americans and Mexican Americans. (Healthy People 2010 Progress Review, Nutrition and Overweight, April 2008 @ www. healthypeople.gov). Rates of obesity (21.4%) and overweight (39.0%) are high in Orange County adults, as they are in the U.S., NYS, and throughout the region. In 2003, the county s reported rates for overweight or obesity (60.4%) were the highest in the HVR, however the rates are not significantly different. County rates exceeded HP2010 targets for both indicators. In NYS, young adults (18-24) were the least likely to be overweight or obese, as were persons who are White, and those with more than a high school education, and household incomes of $50,000 or more. In the county as well as NYS, males were more likely to be overweight than were females; rates for obesity were not significantly different. In 2008, provisional EBRFSS data suggest that rates of overweight and obesity have increased over those reported in 2003, with an estimated 64% of Orange County adults reporting being above healthy weight. Estimates of the prevalence of overweight and obesity in children and adolescents were not measured in the Expanded BRFSS. Nationwide, overweight and obesity in children aged 6 to 11 years increased from 11 percent in 1988 1994 to 17 percent in 2003 2006. In adolescents aged 12 to 19 years, the increase over the same period was from 11 percent to 18 percent. The target for both children and adolescents is 5 percent. Orange County Community Health Assessment 2010-2013 Section I 35

The proportion of children and adolescents who are overweight or obese increased for all racial and ethnic groups surveyed. The proportion of adolescents from low income households who are overweight or obese is twice that of adolescents from middle- and high-income households. Obesity involves complex social, behavioral, cultural, environmental, physiological, and genetic factors. Efforts to maintain a healthy weight by consuming a healthy diet and maintaining regular physical activity should begin in childhood and continue throughout adulthood. Childhood obesity is a priority health concern as the rate of obesity among children ages 6 to 11 in the U.S. has more than tripled over the past 30 years. (HP 2010 Midcourse and Progress Review, Nutrition and Overweight) Core 11: Mammography Breast cancer is the most common cancer among women in the United States, and mortality can be reduced substantially if the tumor is discovered at an early stage. Mammography is the most effective method for early detection, and screening is generally recommended every one to two years for women ages 40+ by the National Cancer Institute (NCI). Orange County women ages 40 and over were queried as to whether they had ever had a mammogram, if they had received a mammogram in the past 2 years, as well as the reason for obtaining a mammogram. Over 86% (86.2%) responded that they had ever had a mammogram and 73.8% had received a mammogram within the past 2 years, meeting the HP2010 target of 70%. The overwhelming majority (91.2%) of respondents had a mammogram as a routine checkup, 4.9% due to a breast problem and 3.9% as a follow-up for breast cancer. Mammography screening rates were comparable to those for the HVR and the state as a whole. Within the state, women ages 50 and over were most likely to be screened, however differences in screening rates by race/ethnicity, income and educational levels were not significant. This is likely due in part to the success of NYSDOH Healthy Women s Partnerships in improving access to low cost/no cost mammography services. Provisional EBRFSS data for 2008 indicate improvement in mammography screening rates. Core 12: Sexual Behavior & Core 13: Family Planning Areas of inquiry on sexual behavior for Orange County adults (18-64) included whether respondents had ever been counseled by a medical professional on STD prevention/condom use, whether they were sexually active, whether condoms had been used during their last intercourse, and if they were sexually active if they had multiple partners in the past 12 months. Family Planning questions for men (ages 18-59) and women (ages 18-44) included whether they used any form of birth control and if not, if they were at risk for pregnancy. Responsible sexual behavior and prevention of unintended pregnancies are important to both reproductive and general health. Unintended pregnancies and sexually transmitted diseases (STDs), including HIV infection can result from unprotected sex. Abstinence is the only method of complete protection, however condoms, if used correctly and consistently, help prevent both unintended pregnancy and STDs. Orange County findings for all indicators are comparable to those in the HVR. When compared with NYS, Orange County adults were more likely to be sexually active, not use condoms, and not have been counseled by a medical professional on STD prevention or condom use. County residents ages 18-34 were more likely to have been counseled on STD prevention or condom use than those ages 35 and over. County residents ages 18-54 were more likely to be sexually active and report condom use than were those 55 and over. The HP2010 target of 50% condom use refers to partners of unmarried women ages 15-44, therefore the aggregate rate of condom use by Orange County adults cannot be evaluated in this context as the data were not collected or analyzed in a comparable manner. Within NYS, younger adults, minorities, and individuals with lower incomes and less education were more likely to have been counseled regarding STD prevention and condom use and use condoms. Contraceptive use by Orange County adults was consistent with the HVR and NYS. HP 2010 targets include the use of contraceptives to prevent all unintended pregnancies 15.6% of Orange County adults at risk for pregnancy reported no contraceptive method, however this figure includes those who were trying to become pregnant. In NYS contraceptive use was most common in adults ages 25-44, with no significant differences reported by gender, race/ethnicity, education or income. Core 14: Cardiovascular Disease Coronary Heart Disease (CHD) and stroke are the two primary components of cardiovascular disease (CVD). These conditions share many of the same modifiable risk factors, including obesity, cigarette smoking, high blood pressure and lack of physical activity. The increasing prevalence of diabetes poses a major and growing threat to heart health as well, in that the proportion of heart disease deaths due to diabetes is projected to increase from 21 to 29 percent of the total over the first quarter of the 21st Century. (Healthy People 2010 Progress Review: Heart Disease and Stroke, May 2003 @ www.healthypeople.gov) Overweight and obesity are growing public health problems that increase risk of CHD and stroke. The lifetime risk for developing CHD is very high in the U.S.: one of every two males and one of every three females currently ages 40 years and under will develop CHD at some point in their life. Lifestyle interventions are the major strategy to reduce the development of heart disease or stroke. (Healthy People 2010) BRFSS questions related to cardiovascular disease included whether the respondent had a physiciandiagnosed heart attack, angina, or stroke or had physician-diagnosed CHD (angina or stroke). HP 2010 targets have not been set for these indicators, and the results for Orange County residents were comparable to those for the HVR and state as a whole. Not surprisingly, reported rates of heart attack, angina, and Orange County Community Health Assessment 2010-2013 Section I 36

stroke were significantly higher in Orange County residents ages 65 and over. Core 15: Prostate Cancer Screening & Core 16: Colorectal Cancer Screening Other than skin cancer, prostate cancer is the most commonly diagnosed form of cancer in males and the second leading cause of cancer death among males in the United States. Prostate cancer is most common in men aged 65 years and older, who account for approximately 80 percent of all cases. Digital rectal examination (DRE) and the prostate-specific antigen (PSA) test are two screening methods for detecting prostate cancer. Clinical trials are currently under way to assess the benefits and risks of screening and treatment, and additional research is needed to identify modifiable risk factors for prostate cancer. Race and age are the only clearly identified risk factors for prostate cancer. African Americans and older men are at higher risk. A reduction in colorectal cancer (CRC) deaths can be achieved through detection and removal of precancerous polyps and early treatment. Research indicates that biennial screening with fecal occult blood tests (FOBT) can reduce deaths from CRC by 15 to 21 percent in people aged 45 to 80 years. The efficacy of sigmoidoscopy is supported by studies that showed 59 to 79 percent reductions in CRC deaths from cancers within reach of the sigmoidoscope in age groups 45 years and older. Nationwide data on CRC show a decline in new cases and death rates in White males and females, stable new case rates in African Americans, and a continued rise in death rates in African American males. Early detection and treatment play a key role in survival rates. (Healthy People 2010) The majority of adult males in the county queried in the 2003 EBRFSS indicated that they had a PSA test (61.5%) and digital rectal exam (78.6%) at sometime, with 53.4% having a PSA test within the past 2 years. These findings were consistent with those for the HVR and NYS. Orange County and NYS males with more education (> high school) were more likely to have ever received a PSA test, and to have received this test within the past 2 years. In NYS, males with more than a high school education were also more likely to have had a digital rectal exam in the past two years. Provisional 2008 EBRFSS data indicate improvement in PSA testing rates. In terms of CRC screening, 2003 survey rates of screening in Orange County were consistent with findings for the HVR and NYS. No significant differences were observed in FOBT testing rates in Orange County adults based on gender, age, or education level. Males and older adults (65 and over) were more likely to have ever had a sigmoidoscopy or colonoscopy, and males were more likely than females to have had at least one of these tests in the past 10 years. In NYS, older adults (65 and over), were more likely to have ever done home-fobt screening as were adults who were White, had higher income, and higher education levels. These same differences did not exist for FOBT screening in the past 1 or 2 years. In NYS, adults ages 50-64 and those who were members of racial/ethnic minorities were less likely to have ever had an endoscopy or to have had this test within the past 2 years. 2008 EBRFSS preliminary results suggest a significant decline in FOBT testing at home (in past 2 years) and an increase in residents reporting sigmoidoscopy and colonoscopy screening. Optional Behavioral Risk Factors Optional Module 4: Cholesterol Awareness Optional Module 9: Fruits and Vegetables Optional Module 12: Hypertension Awareness Optional Module 24: Weight Control A number of studies have shown that lifestyle changes can help prevent high blood pressure and reduce blood cholesterol levels. For high blood pressure, these include increasing physical activity, maintaining a healthy weight, limiting the consumption of alcohol to moderate levels, reducing salt and sodium intake, and eating a low-fat diet high in fruits, vegetables, and lowfat dairy products. Limiting intake of saturated fats (mainly animal fats) while consuming a healthy diet promotes heart health, as does maintaining a healthy weight and regular physical activity. Consuming higher intakes of vegetables (including legumes), fruits, and grains are associated with a variety of health benefits, including a decreased risk for some types of cancer. Overweight and obesity affect the majority of adults placing them at increased risk of high blood pressure, high blood cholesterol and other lipid disorders, Type 2 diabetes, CHD, stroke, and other diseases. (Healthy People 2010) The Dietary Guidelines for Americans recommend three to five servings of various vegetables and vegetable juices and two to four servings of various fruits and fruit juices, depending on calorie needs. In 2003-2004, 40% of U.S. residents over the age of two consumed 2 or more servings of fruit and only 4% consumed at least 3 servings of vegetables each day with one-third being dark green or orange vegetables. (Healthy People 2010 Progress Review, Nutrition and Overweight) Areas of inquiry in the optional modules relating to cholesterol awareness, hypertension awareness, fruit and vegetable consumption and weight control included the following: Ever had blood cholesterol checked/checked within past 5 years In 2003, 82.5% of Orange County adults had ever had their cholesterol checked, and 80% had done so within the past 5 years. These findings are consistent with those in other HVR counties surveyed (Dutchess/Putnam, Rockland, and Westchester). The American Heart Association and National Cholesterol Education Program recommend cholesterol screening every five years for all adults ages 20 and over. The HP2010 goal is 80% for cholesterol screening in adults within the last 5 years. In 2008, provisional data from the EBRFSS indicate an improvement in both of these indicators. Trends in the BRFSS results from 1991-2001 for adults in NYS being told that they have high blood cholesterol follow. Orange County Community Health Assessment 2010-2013 Section I 37

Figure 14 - ADULTS (AGED 18 YEARS AND OLDER) WHO HAVE BEEN TOLD THEY HAVE HIGH BLOOD CHOLESTEROL: NEW YORK BRFSS, 1991-2001 Source: BRFSS Summary Report: High Blood Pressure and High Blood Cholesterol Fall 2004 Ever been told have high blood pressure by a medical professional In 2003, 23.2% of county adults reported being told they had high blood pressure, which is consistent with results from other HVR counties surveyed (Dutchess/Putnam, Rockland, and Westchester), and is above the HP2010 target of 14% for prevalence of hypertension. Provisional data for 2008 suggest that approximately 25% of county adults have high blood pressure and three-fourths of these are taking blood pressure medication. Trends in the BRFSS results for adults in NYS for 1991-2001 are presented below. Figure 15 - ADULTS (AGED 18 YEARS AND OLDER) WHO HAVE BEEN TOLD THEY HAVE HIGH BLOOD PRESSURE: NEW YORK BRFSS, 1991-2001 Source: BRFSS Summary Report: High Blood Pressure and High Blood Cholesterol Fall 2004 Eat Five Fruits or Vegetable Servings per Day In 2003, 25.2% of Orange County residents consumed at least 5 servings of fruits or vegetables per day, which was consistent with findings for the other HVR counties surveyed (Dutchess/Putnam, Rockland, and Westchester). These levels are well below the HP2010 targets of 75% for 2 or more servings of fruits and 50% for 3 or more servings of vegetables. In 2008, provisional data indicate the percentage of county adults reporting 5 or more servings of fruits and vegetables a day increased to 33.1%, which met the PA 2013 target, and fell below the HP 2010 target. Weight Control As previously noted, the prevalence of overweight and obesity in Orange County adults is well above levels recommended for health. Not surprisingly, in 2003 50% of Orange County adults surveyed reported they were trying to lose weight, 79% indicated that they were eating fewer calories or less fat to lose or maintain weight, and 74% indicated that they were using physical exercise to lose or maintain weight. In addition, 54.7% of those queried who were not trying to lose weight indicated that they were trying to maintain their current weight. There were no significant differences in these responses with those in the 2 other HVR counties surveyed Rockland and Westchester. In 2008, preliminary data indicate that 81.3% of Orange County adults reported being advised by a health professional about their weight and advised to lose weight. Optional Module 6: Disability In 2003, 17.9% of Orange County adults indicated that their activities were limited in some way due to physical, mental, or emotional problems, which was comparable to results found in the 2 other counties surveyed in the HVR (Rockland and Westchester). In 2008, provisional data indicate that 18.7% reported disabilities, 17.5% reported activity limitations due to disabilities, and 5.9% reported health problems that required the use of special equipment such as a cane, wheelchair, special bed, or telephone. People with disabilities often have increased health concerns and are more susceptible to secondary conditions. Studies indicate that people with activity limitations have more days of pain, depression, anxiety, and sleeplessness and fewer days of vitality than people without activity limitations. For persons with disabilities it is essential to remove environmental barriers to assure access to medical care. (Healthy People 2010) Census 2000 data for Orange County report 19.6% of the population ages 21 to 64 years of age are disabled; this increases to 39.9% for ages 65 and over. Optional Module 13: Injury Control Falls Orange County adults were queried as to whether they had fallen in the past 3 months a total of 18.5% reported a fall - 11.6% without injury and 6.9% with injury. These results are comparable with other counties surveyed in the HVR (Dutchess/Putnam, Rockland, Westchester). In 2008, preliminary data suggest the percentage of county adults reporting a fall was 15.6% with 4.5% reporting injury as a result of a fall. In the U. S., falls are the leading cause of injury deaths among adults aged 65 years and older, and are the most common cause of hospital admissions for trauma among elderly persons. Since most fractures are caused by falls, understanding factors that contribute to falling is essential to prevention efforts. For all ages combined, alcohol use has been implicated in 35 to 63 percent of deaths from falls. The most serious fall-related injury is hip fracture, and the impact on the quality of life is enormous. Half of all elderly adults hospitalized for hip fracture are unable to return home or live independently after the fracture. (Healthy People 2010) Optional Module 14: Immunization As persons ages 18 and over were surveyed, immunization questions focused on adult vaccination for influenza and pneumonia. CDC recommends both Orange County Community Health Assessment 2010-2013 Section I 38

influenza and pneumonia vaccination for adults in risk categories (such as long-term health conditions, weakened immune system, etc.). If vaccine supply is sufficient, influenza vaccination is recommended for healthy adults ages 50 and over. Pneumonia (pneumococcal) vaccination is also recommended for healthy adults ages 65 and over. In Orange County, 31.6% of adults ages 18 and over reported receiving a flu shot in the past 12 months; this increased to 66.9% for persons ages 65 and over. In the 2008 EBRFSS preliminary percentages were 42.2% and 62.7% respectively. In adults ages 18 and over, 20% reported ever receiving a pneumonia shot, and this increased to 60.4% in persons ages 65 and over. In the 2008 EBRFSS, corresponding preliminary figures were 27.2% and 60.2%. The most relevant indication of the adequacy of vaccination coverage levels is in ages 65 and over, as risk categories of respondents were not assessed. In 2003, coverage levels are consistent for both vaccines with other HVR counties queried (Dutchess/Putnam, Rockland, Sullivan/Ulster, and Westchester), however these were below the HP2010 target of 90% coverage in adults ages 65 and over. Optional Module 15: Oral Health Many persons do not receive preventive and restorative dental services. Through increased access to appropriate and timely care, individuals can enjoy improved oral health. Barriers to care include cost, lack of dental insurance, and fear of dental visits. Dental insurance coverage has not increased. As reported in Healthy People 2010, Only 44 percent of persons in the United States have some form of private dental insurance (most with limited coverage and with high co-payments), 9 percent have public dental insurance (Medicaid and Children s Health Insurance Program), 2 percent have other dental insurance, and 45 percent have no dental insurance. Several national surveys report that the proportion of the U.S. population that annually makes at least one dental visit and the average number of visits made vary significantly by age, race, dental status, level of education, and family income. Oral health indicators surveyed included whether adults ages 18 and over had ever had permanent teeth removed because of tooth decay or gum disease and whether they had seen a dental professional in the past 12 months. Over half (51%) of Orange County adults had permanent teeth removed, compared with the HP 2010 target of 40% (for ages 35-44). Preliminary data from the 2008 EBRFSS survey suggest a decline in this indicator. In the 2003 EBRFSS, nearly three-fourths (73.7%) of county residents had seen a dental professional in the past 12 months, which met the HP 2010 target of 56%, but fell short of the PA 2013 target of 83%. In the 2008 EBRFSS, provisional data suggest that 71.9% of county residents surveyed reported a dentist visit in the past year and 71.7% reported having their teeth cleaned. In 2003, Rockland County was the only additional HVR county surveyed for this indicator Orange County results were comparable for permanent teeth extractions but were significantly lower for having seen a dental professional. Although not part of the EBRFSS, in 2003 the oral health status of 3 rd grade children was assessed by the NYSDOH in collaboration with the CDC. Nearly 80% of NYS children have experienced dental decay (a preventable disease) by the end of high school. The survey included a self-administered questionnaire completed by parent/guardian and an oral screening by a licensed dentist or hygienist with the written consent of parent/guardian. The results for the representative sample of 6 schools surveyed in Orange County follow: Figure 16 - NYSDOH ORAL HEALTH SURVEY OF THIRD GRADE CHILDREN SUMMARY RESULTS FOR ORANGE COUNTY, 2003 County HP 2010 Target Orange County Standard Error (+/-) # of Children Screened 347 8 schools Caries Experience Untreated Caries Sealants 42.0% 21.0% 50.0% Dental Insurance Fluoride Supplements Visit in past 12 mos. 55.7% 36.3% 31.8% 74.5% 27.6% 70.0% 2.9 3.2 3.0 1.7 3.8 3.8 Optional Module 25: Cervical Cancer Considerable evidence suggests that screening can reduce the number of deaths from cervical cancer. Precancerous changes in cervical tissue commonly precede invasive cancer that can be identified with a Papanicolaou (Pap) test. If cervical cancer is detected early, the likelihood of survival is almost 100 percent with appropriate treatment and follow-up. NCI general screening recommendations for adult women include a Pap test every 3 years, until at least age 65 to 70. Cervical cancer is the 10th most common cancer among females in the United States, and the number of new cases of cervical cancer is higher among minority females than among White females. Infections of the cervix with certain types of sexually transmitted human papilloma virus increase risk of cervical cancer and may be responsible for most cervical cancer in the United States. (Healthy People 2010) The HP2010 target for ever having had a Pap test is 97%; 96.4% of women in Orange County reported ever having this test in 2003 and provisional data indicate this was 94% in 2008. In 2003, 85.9% of women reported having a Pap test within the past 3 years; provisional data for 2008 suggest this was 84.1%, both of which are below the HP2010 target of 90%. Findings for both indicators are comparable with those found for other counties surveyed within the HVR (Rockland, Sullivan/Ulster, and Westchester. Selected Youth Behavioral Risk Factors A comprehensive needs assessment entitled Orange County Community Needs Profile, part of the Integrated County Planning process, was developed by the Orange County Youth Bureau; Department of Social Services; and Partners for Children, Youth and Families in October 2006. (www.co.orange.ny.us) This assessment addresses additional behavioral risk factors for Orange County youth, several of which follow. Orange County Community Health Assessment 2010-2013 Section I 39

Sexual Behavior and Teenage Pregnancy From 2000-2005, Planned Parenthood of the Mid-Hudson Valley reported an increase in the number of positive pregnancy results in adolescents up to age 19 tested (from 17% to 21.5%). Recently released data from NYSDOH related to adolescent pregnancy rates for 2004-2006 show that although Orange County rates are below state averages, pregnancy rates are considerably higher than regional averages for ages 15-17. Mental and Behavioral Health For 2004-2006, Orange County s adolescent suicide mortality rate (per 100,000 residents ages 15-19) was 5.7. This rate was higher than NYS and the HVR average; however it is unstable due to the relatively low number of events. (Exhibit 1.C3) SPARCS data for 2004-2006 show that the hospitalization rate for Orange County adolescents (ages 15-19) due to self-inflicted injury (10.9 per 10,000) was comparable to the average for the region (10.8) and above the rate for NYS and ROS. Based NYS Kids Well-Being data, Orange County rates for Young Adult Property Crimes and Violent Crimes (Ages 16-21) were higher than the rates for ROS; both indicators showed a reduction from 2006-2007. Orange County Community Health Assessment 2010-2013 Section I 40

SECTION ONE: POPULATIONS AT RISK D. THE LOCAL HEALTH CARE ENVIRONMENT 1. History The earliest carbon dated human settlement in North America, over 12,500 years old, is found in Orange County. Mastodons roamed the same area and more of their skeletons can be found here than any place on Earth. In 1683 Orange County was established as one of the original 12 counties of the Province of New York. The county s name originates from King William III of England who was a Prince of the House of Orange. In 1609 Henry Hudson sailed up the Hudson River and anchored the "Half Moon" in Cornwall Bay. George Washington established his longest residency during the Revolutionary War in Newburgh. It was here that he founded the Order of the Purple Heart, and in 1850 Washington's Headquarters became the first Registered National Historic Landmark in the United States. The original boundaries of the county included what is now Rockland County. In 1798, Rockland County was separated from Orange County. Also of historical significance is that Orange County is home to the oldest military academy in the United States, the U.S. Military Academy at West Point. The Academy has produced military heroes of great renown such as Eisenhower, Patton, and Schwartzkopf and is one of the most popular tourist attractions in the northeast. The ecological movement in the United States began here at Storm King Mountain overlooking the Hudson River when environmentalists prevented a utility company from destroying the mountain. Within the county is Stewart International Airport, an alternate site for landing the space shuttle, since the airport has one of the longest runways in the United States. (www.co.orange.ny.us) 2. Physical and Social Factors Geography Orange County is located in the Hudson Valley Region of New York State, approximately 40 miles north of NYC. Orange is the only New York County positioned between two rivers, the Hudson on the east, and the Delaware on the west. Ulster and Sullivan Counties border the county on the north, Rockland County to the south, and Passaic and Sussex County New Jersey and Pike County Pennsylvania to the southwest (Exhibit 1D.1). Topographically, much of Orange County includes the Shawngunk Ridge (also known as the Shawngunk Mountains) which extends from the northernmost point of New Jersey to the Catskill Mountains. The county also has large valley areas. The total area of the County is 839 square miles: 816 square miles are land and the remaining 22 square miles are water. (www.census.gov) Although the county s roadway infrastructure is well developed, the natural topography limits road construction and travel in certain areas of the county. Orange County has long been known as an important farming and agricultural center in the state. This includes the past production of Goshen Gold premium butter, and the county s famous black dirt soil, rich in organic nutrients. According to Orange County Cornell Cooperative Extension, in 2000 there were 740 farms remaining in the county. Orange County ranks 21st in the state for number of farms and 39th for area being farmed. It ranks first in the state for production of onions and pumpkins and second in vegetable production. While not included in agricultural statistics, the equine industry is also a major component of Orange County agriculture. One hundred breeding and boarding facilities operate in the county, and there are an estimated 7,800 horses in the county. (www.cce.cornell.edu/~orange/orange.htm ) The rural nature of certain areas in the county presents challenges in the containment of rabies in wildlife and also the transmission of Lyme Disease and other tickborne diseases. The presence of farms attracts a large migrant farm worker population for seasonal employment, a number of whom travel with their families and remain in the county throughout the year. The health care needs of the Migrant Farm Worker population are served in large part through the Migrant Health Center located in Goshen, which is administered by Hudson River Community Health. The migrant farm worker population in the county is predominately Hispanic/Latino immigrants from Mexico and Central America. Lack of insurance coverage is a known barrier to obtaining health care and is compounded by other factors including lack of transportation, inflexible work schedules, language difficulties, and lack of knowledge of the importance and availability of primary care. Migrant farm workers also present with a number of specialized health care needs related to occupational pesticide exposure, skin problems, poor oral health Orange County Community Health Assessment 2010-2013 Section I 41

and dental disease, diabetes, and sexually transmitted diseases. Alcohol and substance abuse and depression are additional areas of need in this population. Impact of Population Growth As noted in Section 1A - Demographics, population growth in Orange County has been significant over the past 30 plus years (1970-2007). In 2007, Orange County ranked first out of the 62 counties in New York in its rate of growth based on Census population estimates. The once rural landscapes of the county are being replaced in part by suburban and business developments. Even with the economic downturn, migration into the county continues to be steady due to its relatively affordable housing, excellent education system, desirable recreation and leisure opportunities, growing business community and employment opportunities. In addition to health planning, population growth offers great opportunities and also challenges in planning which are addressed in the County Comprehensive Plan, Parks Plan, Agriculture and Farmland Preservation Plan and Open Space Plan. Orange County residents continue to enjoy large areas of open space there are 86,637 acres of parkland in the county. Both State and County Parks provide diverse recreational opportunities for residents and visitors. In addition, the Hudson and Delaware Rivers provide water recreational activities as do the many lakes and ponds located in the county. Due to the amount of open space, there are a sizable number of summer camps and camping facilities requiring inspection by OCDOH environmental staff. The population increase has brought increased demands on the health care delivery systems in the county providing primary, acute and specialty care. As discussed in Section 1B Access to Care, there is an expanding need for both primary and specialty health care providers serving the uninsured and Medicaid population in the county. The growth rate in the minority population in Orange County has exceeded the rate of growth for non-minorities. As noted in Section 1A, this presents challenges in the delivery of culturally and linguistically appropriate care, and in the recruitment of a more diverse health care workforce. The hospitals and medical centers located in the county have been responsive to the growing demand for services by expanding their care networks and the continuum of services available locally to residents including outpatient specialty services. At the present time, one acute care hospital in the county is in the process of constructing a new facility of approximately 375-400 beds. (www.ocmc.org) In 2004, the Catskill-Hudson Area Health Education Center conducted focus groups with health providers and educators in the region, and the major concerns and needs expressed about local health care and the quality, supply, and distribution of health professionals related to the rapid expansion in population included the following: The close proximity of Putnam, Dutchess, Sullivan, and Orange Counties to the NYC Metropolitan area creates a competitive disadvantage both in recruiting health care workers and in retaining patients. A more diverse health professional workforce is needed with greater cultural competency. Dental professionals are electing to practice in larger urban centers instead of remaining in the region. Low paying, entry level health care positions are difficult to recruit for and many workers have literacy and language challenges. The high cost of care and lack of insurance/insufficient insurance, particularly among undocumented immigrants presents a barrier to care. Inadequate reimbursement rates for hospitals/physicians and rising malpractice costs are factors in recruiting and retaining health providers in the region. Additional nursing, medical, dental, mental health and allied health professionals, particularly those serving the uninsured and underinsured, and specialty providers are needed. Housing Availability and Affordability The number of housing units in the county increased by nearly 11% (10.8%) from 1990 to 2000, which is consistent with the overall rate of growth in the population during this time. In 2000, nearly 20% of owner-occupied housing units in the county were valued at $ 200,000 or more. The vast majority of housing units in the county are owner-occupied; however in Orange County s 3 cities the reverse is true with the majority of housing units being renteroccupied. Two-thirds (67%) of the occupied housing units in the county were owner-occupied in 2000; in the cities this decreased to less than 40% (39.4%). There are relatively few housing vacancies in the county; 6.5% of all housing units were vacant in 2000. According to the 2000 Census, 2.2% of Orange County housing units lacked complete plumbing or heating facilities or telephones; in the county s 3 cities this ranged from 5.4% to 6.8%. As noted in Section 1A, Orange County s cities contain a high proportion of pre -1950 housing stock which is a factor in lead poisoning risk. Property values and housing costs in the county have risen significantly over the past decade due to the increased demand for housing, and as a result low income individuals and families often cannot find affordable housing. Low income individuals and families include those working at minimum wage, retirees on fixed incomes, and young adults just starting into the workforce. Cost-burdened renters are defined as persons expending 30% of more of their gross monthly income for rent. Nearly 40% of Orange County households who rent met this definition in 2000. In low income areas of the county, the percentage of cost burdened renters increases substantially. To encourage the development of affordable rental housing in Orange County, the Office of Community Orange County Community Health Assessment 2010-2013 Section I 42

Development administers the Affordable Rental Production Program. This program offers economic incentives to builders, such as grants and loans, as part of the Federal HOME Investments Partnerships Program. One consequence of the scarcity of affordable rental housing is the potential for the creation of illegal apartments. As these units are not inspected by housing authorities, they may pose significant safety and health risks to their occupants. Although the number of such units is unknown, it is reasonable to assume that with the increase in the undocumented population in certain areas of the county, the number of persons living in such conditions has increased. Housing facilities for migrant farm workers are inspected prior to occupancy and while in use by the environmental staff of OCDOH. 3. Economic Factors Overall, Orange County residents enjoy a high standard of living. The per capita income in 2000 was $21,597, and the median family income was $60,355. In comparison, the per capita income for the entire State was $ 23,389, and the median family income was $ 51,691. Within the HVR, Orange County ranks 5 th out of the 7 counties in the region in median income and third in the percentage of individuals living below the poverty level. Overall levels of poverty in the county have risen from 1990 to 2000 - in 1990 6.4% of families in Orange County were living below the poverty level and this increased to 7.6% in 2000. Nonetheless, the percentage of families and individuals living in poverty in Orange County remains well below state averages. The number of families with incomes over $150,000 per year increased substantially during this same time, from 1.6% to 5.6%. One and three-year estimates from the 2005-2007 American Community Survey show positive gains in family income since 2000. (www.census.gov) Lack of insurance or insufficient coverage, which is closely linked to income, persists as a significant barrier to accessing health care for county residents (See Section IB). Environmental and Legal Factors Air and Water Quality Ambient Air Quality Orange County s air quality is generally acceptable for most pollutants monitored by the NYS Department of Environmental Conservation in the Hudson Valley Region (Region 3) with the exception of ozone levels in some areas that sometimes exceed the United States Environmental Protection Agency's National Ambient Air Quality Standard of 0.08 ppm as a running 8-hour average. (www.state.ny.us) Orange County, as well as the other counties in the Hudson Valley and Metropolitan Region, may experience higher than recommended levels of ozone, especially on hot, sunny summer days. An ozone health advisory is issued when the ozone concentrations in outdoor air are expected to exceed the standard because ozone exposure has been linked with adverse health effects, especially for those with respiratory conditions. Indoor Air Quality - On July 24, 2003 revisions to the NYS Clean Indoor Act (CIAA) became effective and prohibited smoking in indoor public areas throughout the county instead of merely restricting it. This has led to a significant reduction in environmental tobacco smoke exposure by county residents in public facilities. Drinking water in Orange County is obtained from a number of reservoirs and underground water resources (aquifers). The following water systems are served by reservoirs: cities of Middletown, Newburgh, and Port Jervis; town of Newburgh; villages of Chester, Florida, Goshen, Highland Falls, Monroe, Tuxedo Park, Warwick; several systems in the Sterling Forest area, and the U.S. Military Academy at West Point. This water is distributed to county residents by 513 public water systems (170 community systems and 409 noncommunity systems). Public water systems use approximately 800 supply wells. An estimated 75% of the county s water supply is delivered via public systems; the remaining 25% is delivered via private wells. The water delivered by Orange County public water systems is of excellent quality, meeting and typically exceeding local, state and federal drinking water standards and guidelines. Over 24 inorganic substances, and about 100 organic substances (including pesticides) are routinely monitored as well as microbiological and radiological activity, corrosivity, color, and odor. According to the 2003 NYSDOH Oral Health Survey, presently 26% of Orange County s population on public water systems is receiving fluoridated water. The rate of population growth has resulted in the need to expand public water systems in many areas of the county, and to integrate more advanced technology in both the identification of water resources and in water monitoring systems. A major focus of the County s recently developed Open Space Plan is to preserve and protect the reservoir and watershed areas serving county residents. Climate The climate of Orange County is influenced both by its proximity to the water and its topography, including high elevations in the Shawnangunk Mountains. The mean annual temperatures by season are: 50.3 F in the spring, 72.7 F in the summer, 54.6 F in the fall and 29.5 F in the winter. Annual precipitation is 48 inches of rain and 38 inches of snow. (www.orangeny.com) Severe weather is an infrequent hazard in the county although disaster preparedness, including natural disasters such as blizzards, floods, hurricanes, and tornados, is a component of OCDOH all hazards planning. Bioterrorism and Public Health Preparedness Isolation and Quarantine In New York State, Public Health Law 2100 authorizes broad powers to County Health Commissioners to impose isolation and quarantine restrictions in the event of a natural or intentional outbreak of communicable diseases (as designated in the State Sanitary Code) to control and contain the transmission of disease within their jurisdictions. Isolation is defined in NYCRR 2.25 (d) as consisting of the separation from other persons, in such place, under such conditions, and for such time, as will prevent transmission of the infectious agent or Orange County Community Health Assessment 2010-2013 Section I 43

persons known to be ill or suspected of being infected. Quarantine of premises is defined in NYCRR 2.25 (e) to consist of (1) prohibition of entrance into or exit from the premises, as designated by the health officer, where a case of communicable disease exists of any person other than medical attendants and such others as may be authorized by the health officer; (2) prohibition, without permission and instruction from the health officer, or the removal from such premises of any article liable to contamination with infective material through contact with the patient or with his secretions or excretions, unless such article has been disinfected. The decision of whether or not to quarantine or isolate individuals is based on the type of event and the nature of the disease agent. As part of public health emergency planning, the Orange County Commissioner of Health and Director of the Office of Public Health Emergency Response have integrated policies and procedures for isolation and quarantine specific to bioterrorism agents into county public health emergency preparedness plans. Transportation Services The overwhelming majority of county residents use private automobiles for travel. In 2000, 76.6% of the workforce commuted in their own cars, 11.1% carpooled, 4.7% used public transportation and 4.2% walked to work. (Census 2000) The roadway infrastructure within the county is well developed and major routes such as I-87, (running north-south on the eastern side of the county), I-84 (running east-west through the interior of the county), and Rt. 17 (future I- 86) (running southeast-northwest through the interior of the county), facilitate travel by car both within and outside of the county. In addition to personal automobiles, commuters rely on mass transit (bus and rail) service into the metropolitan region. As previously noted in Section 1B, access to health care might be improved by expanded and more frequent public transportation, especially in low income areas. The rapid rate of growth in the county has increased congestion on the county s roadways, particularly during peak commuting hours. As a result the risk for motor vehicle accidents is increased, as well as the volume of exhaust emissions released into the environment. Media and Technology Orange County residents have access to a variety of media outlets for health information. The county is served by 2 daily and 16 weekly newspapers/publications. Residents can access a number of AM and FM radio stations in the HVR and are within the broadcasting area of a large number of stations in the metropolitan area. There are 4 cable TV companies in the county, each with their own local access cable channel. In addition to print and radio media, cable, satellite and network television, the Internet provides unprecedented access to health information. The Internet assists health consumers in being well informed about health issues; at the same time it also increases the potential for health misinformation as the quality of Internet-based health information is not regulated and is dependent upon the source. OCDOH maintains a website with recommended links for health information and also provides this information on request to the public. The potential impact of media on health behaviors is significant for children, adolescents and adults. For example, research cited in the State of Vermont s Health Plan indicates that alcohol, tobacco, or illicit drugs are present in 70% of prime time TV programs. (www.state.vt.us/health). The Journal of Medical Internet Research, a peer reviewed e-health journal, recently conducted a study on the effectiveness of the Internet as a communication tool for bioterrorism information. This study found that persons trusted health information from physicians the most, and health websites were valued slightly above other traditional media sources. The study also concluded that the utility of the Internet to provided quality health information will not be fully realized until access is improved in economically disadvantaged population groups. (The Internet as a Vehicle to Communicate Health Information During a Public Health Emergency@ www.jmir.org) Orange County Community Health Assessment 2010-2013 Section I 44

ORANGE COUNTY COMMUNITY HEALTH ASSESSMENT 2010-2013 SECTION ONE EXHIBITS Orange County Community Health Assessment 2010-2013 Section I 45

TRENDS IN ORANGE COUNTY MUNICIPAL POPULATION, 1970-2000 A. Year % Change Towns 2000 1990 1980 1970 1980-1990 1990-2000 1970-2000 Orange County 341,367 307,647 259,603 221,657 18.5 11.0 54.0 Blooming Grove (T) 17,351 16,673 12,339 8,813 35.1 4.1 96.9 Chester (T) 12,140 9,138 6,850 4,767 33.4 32.9 154.7 Cornwall (T) 12,307 11,270 10,774 9,672 4.6 9.2 27.2 Crawford (T) 7,875 6,394 4,910 3,896 30.2 23.2 102.1 Deerpark (T) 7,858 7,832 5,633 4,370 39.0 0.3 79.8 Goshen (T) 12,913 11,500 10,463 8,393 9.9 12.3 53.9 Greenville (T) 3,800 3,120 2,085 1,379 49.6 21.8 175.6 Hamptonburgh (T) 4,686 3,910 2,945 2,204 32.8 19.9 112.6 Highlands (T) 12,484 13,667 14,004 14,661-2.4-8.7-14.8 Middletown (C) 25,388 24,160 21,454 22,607 12.6 5.1 12.3 Minisink (T) 3,585 2,981 2,488 1,942 19.8 20.3 84.6 Monroe (T) 31,407 23,035 14,948 9,190 54.1 36.3 241.8 Montgomery (T) 20,891 18,501 16,576 13,995 11.6 12.9 49.3 Mount Hope (T) 6,639 5,971 4,398 2,966 35.8 11.2 123.8 Newburgh (C) 28,259 26,454 23,438 26,219 12.9 6.8 7.8 Newburgh (T) 27,568 24,058 22,747 21,593 5.8 14.6 27.7 New Windsor (T) 22,866 22,937 19,534 16,650 17.4-0.3 37.3 Port Jervis (C) 8,860 9,060 8,699 8,852 4.2-2.2 0.1 Tuxedo (T) 3,334 3,023 3,069 2,967-1.5 10.3 12.4 Wallkill (T) 24,659 23,016 20,481 11,518 12.4 7.1 114.1 Warwick (T) 30,764 27,193 20,976 16,956 29.6 13.1 81.4 Wawayanda (T) 6,273 5,518 4,298 3,408 28.4 13.7 84.1 Woodbury (T) 9,460 8,236 6,494 4,639 26.8 14.9 103.9 B. Year % Change Villages 2000 1990 1980 1970 1980-1990 1990-2000 1970-2000 Chester (V) 3,445 3,270 1,910 1,627 71.2 5.4 111.7 Cornwall on Hudson (V) 3,058 3,093 3,164 3,131-2.2-1.1-2.3 Florida (V) 2,571 2,497 1,947 1,674 28.3 3.0 53.6 Goshen (V) 5,676 5,255 4,874 4,342 7.8 8.0 30.7 Greenwood Lake (V) 3,411 3,208 2,809 2,262 14.2 6.3 50.8 Harriman (V) 2,252 2,288 796 955 187.4-1.6 135.8 Highland Falls (V) 3,678 3,937 4,187 4,638-6.0-6.6-20.7 Kiryas Joel (V) 13,138 7,437 2,088 NA 256.2 76.7 NA Maybrook (V) 3,084 2,802 2,007 1,536 39.6 10.1 100.8 Monroe (V) 7,780 6,672 5,996 4,439 11.3 16.6 75.3 Montgomery (V) 3,636 2,696 2,316 1,533 16.4 34.9 137.2 Otisville (V) 989 1,078 953 933 13.1-8.3 6.0 Tuxedo Park (V) 731 706 809 861-12.7 3.5-15.1 Unionville (V) 536 548 574 576-4.5-2.2-6.9 Walden (V) 6,164 5,836 5,659 5,277 3.1 5.6 16.8 Warwick (V) 6,412 5,984 4,320 3,604 38.5 7.2 77.9 Washingtonville (V) 5,851 4,906 2,380 1,887 106.1 19.3 210.1 Town (T) totals include villages. Source: U.S. Bureau of the Census Exhibit 1A.1 46

A SLICE OF ORANGE. CENSUS 2000 PROFILE A. Municipalities B. Municipal Population Land Area Population Households Families 2000 Sq Miles Density Persons Persons Per Housing Per Unit Family Units Median Age Orange County 341,367 816.4 418.1 114788 84457 2.9 3.4 122754 34.7 Blooming Grove (T) 17,351 34.9 497.6 5836 4574 3.0 3.4 6559 35.9 Chester (T) 12,140 25.2 482.3 3848 3015 2.9 3.3 3984 37.3 Cornwall (T) 12,307 26.8 459.0 4625 3328 2.7 3.2 4852 38.2 Crawford (T) 7,875 40.1 196.3 2707 2132 2.9 3.3 2851 36.0 Deerpark (T) 7,858 66.4 118.3 2906 2115 2.7 3.1 3332 37.8 Goshen (T) 12,913 44.0 294.0 4074 2911 2.7 3.3 4320 38.8 Greenville (T) 3,800 30.3 126.0 1243 1024 3.0 3.3 1365 36.1 Hamptonburgh (T) 4,686 26.6 176.2 1467 1227 3.1 3.4 1532 38.3 Highlands (T) 12,484 30.9 404.0 3230 2323 2.7 3.3 3418 22.7 Middletown (C) 25,388 5.0 5129.0 9466 5963 2.6 3.3 10124 33.4 Minisink (T) 3,585 23.1 155.2 1182 946 3.0 3.4 1245 36.4 Monroe (T) 31,407 20.1 1564.1 8228 6882 3.7 4.1 8517 22.5 Montgomery (T) 20,891 50.4 414.3 7273 5448 2.8 3.3 7643 35.3 Mount Hope (T) 6,639 25.2 263.5 1582 1218 2.9 3.3 1714 36.3 Newburgh (C) 28,259 3.8 7398.0 9144 6078 3.0 3.6 10476 27.8 Newburgh (T) 27,568 43.7 631.0 9765 7521 2.8 3.2 10122 37.8 New Windsor (T) 22,866 34.8 657.0 8396 6078 2.7 3.2 8759 36.7 Port Jervis (C) 8,860 2.5 3488.2 3533 2160 2.5 3.2 3851 35.6 Tuxedo (T) 3,334 47.5 70.2 1337 963 2.5 2.9 1457 40.7 Wallkill (T) 24,659 62.2 397.0 8866 6328 2.7 3.2 9283 36.3 Warwick (T) 30,764 101.6 303.0 10868 7957 2.7 3.3 11818 38.3 Wawayanda (T) 6,273 35.2 178.3 2095 1719 3.0 3.3 2174 37.1 Woodbury (T) 9,460 36.2 262.0 3117 2547 3.0 3.4 3358 35.8 Municipal Population Land Area Population Households Families Persons Persons Per Housing Villages 2000 Sq Miles Density Per Unit Family Units Median Age Chester (V) 3,445 2.1 1625.0 1396 902 2.5 3.0 1455 35.5 Cornwall on Hudson (V) 3,058 2.0 1568.2 1181 824 2.6 3.1 1233 38.9 Florida (V) 2,571 1.9 1360.3 951 705 2.7 3.2 974 37.9 Goshen (V) 5,676 3.2 1768.2 2039 1228 2.4 3.1 2150 38.0 Greenwood Lake (V) 3,411 2.1 1664.0 1332 878 2.6 3.2 1534 37.1 Harriman (V) 2,252 1.0 2275.0 927 589 2.4 3.1 958 35.2 Highland Falls 3,678 1.1 3344.0 1567 923 2.4 3.1 1657 38.2 Kiryas Joel (V) 13,138 1.1 11944.0 2229 2138 5.7 5.8 2233 15.0 Maybrook (V) 3,084 1.3 2319.0 1043 780 3.0 3.4 1077 31.8 Monroe (V) 7,780 3.4 2288.2 2569 2101 3.0 3.4 2620 36.3 Montgomery (V) 3,636 1.4 2693.3 1304 972 2.8 3.2 1338 35.3 Otisville (V) 989 0.7 1374.0 356 251 2.8 3.3 373 36.7 Tuxedo Park (V) 731 2.7 273.0 291 215 2.5 2.9 363 44.6 Unionville (V) 536 0.3 2144.0 197 140 2.7 3.2 210 38.4 Walden (V) 6,164 2.0 3113.1 2197 1578 2.8 3.3 2352 33.8 Warwick (V) 6,412 2.2 2941.3 2523 1619 2.5 3.2 2615 40.0 Washingtonville (V) 5,851 2.6 2268.0 1984 1498 2.9 3.5 2044 35.3 Town totals include villages. Source: US Bureau of the Census Prepared by: Kathy V. Murphy, Orange County Department of Planning Exhibit 1A.2a 47

http://www.orangecountygov.com/documentview.asp?sessionid=caaiibbajcbcejjjjia&docid=5280 Exhibit 1A.2b 48

ORANGE COUNTY POPULATION DENSITY MAP, 2000 Source: US Bureau of the Census Prepared by Kathy V. Murphy, Department of Planning Exhibit 1A. 3 49

ORANGE COUNTY POPULATION GROWTH MAP, 1990-2000 Exhibit 1A.4 50

AGE DISTRIBUTION BY MUNICIPALITY, ORANGE COUNTY, 2000 POPULATION BY AGE Municipalities Total 0-4 5-9 10-17 18-20 21-24 25-34 35-44 45-54 55-64 65-74 75-84 85+ Orange County 341367 25970 28746 44440 14402 15249 43419 59099 47221 27636 18256 12294 4635 Blooming Grove (T) 17351 1229 1523 2475 581 554 1999 3358 2699 1494 825 494 120 Chester (T) 12140 866 971 1484 320 354 1496 2604 2086 1029 568 277 85 Cornwall (T) 12307 824 995 1617 337 303 1367 2279 1956 1099 808 557 165 Crawford (T) 7875 527 670 1190 254 227 905 1475 1203 696 408 237 83 Deerpark (T) 7858 500 603 1056 233 265 900 1409 1171 858 479 305 79 Goshen (T) 12913 684 933 1540 421 512 1513 2164 1818 1148 783 747 650 Greenville (T) 3800 256 338 559 135 109 425 723 601 327 172 116 39 Hamptonburgh (T) 4686 310 386 664 155 148 409 876 801 430 252 153 102 Highlands (T) 12484 888 889 1072 2052 1953 1612 1722 1014 513 420 269 80 Middletown (C) 25388 1998 2034 3023 1067 1329 3892 3967 3147 1895 1371 1193 472 Minisink (T) 3585 237 305 527 119 107 405 716 548 324 160 103 34 Monroe (T) 31407 4034 3748 5262 1967 1676 3644 4156 3526 1568 1025 600 201 Montgomery (T) 20891 1452 1776 2901 697 816 2706 3787 2953 1617 1145 782 259 Mount Hope (T) 6639 293 396 678 183 300 1249 1541 1028 506 292 128 45 Newburgh (C) 28259 2766 2751 3862 1787 1814 4279 3859 2655 1889 1284 951 362 Newburgh (T) 27568 1840 2138 3236 859 948 3355 4946 4055 2728 1905 1172 386 New Windsor (T) 22866 1592 1745 2727 709 907 3048 4096 3217 1965 1505 1038 317 Port Jervis (C) 8860 677 667 1117 325 423 1142 1364 1089 706 647 508 195 Tuxedo (T) 3334 188 219 315 77 82 397 633 602 430 225 137 29 Wallkill (T) 24659 1621 1843 3003 821 1057 3456 4167 3732 2290 1357 929 383 Warwick (T) 30764 2010 2455 3900 829 903 3414 6201 4858 2721 1846 1198 429 Wawayanda (T) 6273 411 522 919 203 180 684 1205 1004 548 352 204 41 Woodbury (T) 9460 767 839 1313 271 282 1122 1851 1458 855 427 196 79 B. POPULATION BY AGE Villages Total 0-4 5-9 10-17 18-20 21-24 25-34 35-44 45-54 55-64 65-74 75-84 85+ Chester (V) 3445 235 242 331 96 157 625 638 464 280 215 127 35 Cornwall on Hudson (V) 3058 175 242 408 89 81 315 539 495 308 188 158 60 Florida (V) 2571 174 196 316 73 86 315 461 395 226 175 123 31 Goshen (V) 5676 271 359 638 230 273 804 871 726 469 367 378 290 Greenwood Lake (V) 3411 215 263 430 91 115 439 726 484 293 192 131 32 Harriman (V) 2252 155 170 264 58 75 395 465 298 151 131 67 23 Highland Falls 3678 207 249 427 113 147 508 618 508 325 305 204 67 Kiryas Joel (V) 13138 2677 2180 2700 1178 1083 1449 725 855 87 86 96 22 Maybrook (V) 3084 235 268 504 121 133 420 591 417 168 104 95 28 Monroe (V) 7780 558 691 1036 250 247 912 1497 1184 673 419 232 81 Montgomery (V) 3636 259 318 475 100 127 518 665 517 300 193 134 30 Otisville (V) 989 55 65 159 44 43 103 167 163 83 61 29 17 Tuxedo Park (V) 731 45 49 68 16 21 58 112 159 114 54 29 6 Unionville (V) 536 34 40 67 14 18 60 110 84 54 26 22 7 Walden (V) 6164 444 549 867 228 273 849 1090 802 434 337 225 66 Warwick (V) 6412 405 505 777 160 177 666 1128 910 503 492 460 229 Washingtonville (V) 5851 442 556 884 210 162 641 1208 817 386 284 205 56 *Town totals include villages. Source: U.S. Bureau of the Census Exhibits 1A. 5a 51

AGE DISTRIBUTION BY MUNICIPALITY, ORANGE COUNTY, 1990 A. Age Municipalities Total 0-4 5-9 10-17 18-20 21-24 25-34 35-44 45-54 55-64 65-74 75-84 85 + Orange County 307647 25627 24426 35008 15175 17842 53278 49620 31720 22867 18188 10652 3244 Blooming Grove (T) 16673 1461 1314 1848 602 705 3065 3160 2073 1241 759 358 87 Chester (T) 9138 745 656 1148 372 511 1719 1573 1123 632 406 210 43 Cornwall (T) 11270 836 833 1223 406 502 1748 2004 1247 1007 845 484 135 Crawford (T) 6394 519 492 785 276 331 1018 1135 739 463 346 231 59 Deerpark (T) 7832 649 660 872 270 369 1332 1253 920 629 535 285 58 Goshen (T) 11500 672 745 1334 545 623 1817 1927 1363 897 665 564 348 Greenville (T) 3120 237 286 401 128 129 470 603 380 198 156 104 28 Hamptonburgh (T) 3910 258 336 516 159 185 505 715 519 282 203 133 99 Highlands (T) 13667 909 833 1046 2674 2273 2119 1583 833 629 438 266 64 Middletown (C) 24160 2055 1809 2437 1058 1600 4496 3452 2087 1745 1764 1218 439 Minisink (T) 2981 272 261 368 125 142 488 514 337 214 143 93 24 Monroe (T) 23035 2625 2592 3898 1305 1026 3212 3576 1887 1270 939 579 126 Montgomery (T) 18501 1500 1501 2177 778 973 3228 2995 1827 1383 1188 729 222 Mount Hope (T) 5971 365 378 598 202 384 1431 1142 660 380 256 146 29 Newburgh (C) 26454 2652 2395 3022 1672 1874 4671 3337 2221 1776 1605 964 265 Newburgh (T) 24058 1683 1652 2561 868 1217 4036 3833 2933 2391 1734 863 287 New Windsor (T) 22937 2028 1791 2282 777 1168 4547 3671 2190 1829 1597 857 200 Port Jervis (C) 9060 807 722 926 361 512 1575 1201 773 770 808 461 144 Tuxedo (T) 3023 171 166 252 85 138 487 515 430 343 236 138 62 Wallkill (T) 23016 1738 1735 2788 1032 1264 3982 4046 2532 1619 1339 728 213 Warwick (T) 27193 2280 2085 2809 954 1287 5063 4851 2970 2165 1592 912 225 Wawayanda (T) 5518 454 494 692 207 208 881 1004 625 433 343 144 33 Woodbury (T) 8236 711 690 1025 319 421 1388 1530 1051 571 291 185 54 B. Age Villages Total 0-4 5-9 10-17 18-20 21-24 25-34 35-44 45-54 55-64 65-74 75-84 85 + Chester(V) 3270 297 203 241 111 201 915 475 280 226 189 113 19 Cornwall on Hudson(V) 3093 181 207 350 101 144 418 520 387 290 286 164 45 Florida(V) 2497 225 190 252 78 103 442 422 265 205 192 102 21 Goshen(V) 5255 308 317 501 248 341 995 839 579 419 342 247 119 Greenwood Lake(V) 3208 321 260 268 106 161 667 497 315 246 211 123 33 Harriman(V) 2288 242 141 164 54 120 730 327 162 122 126 87 13 Highland Falls(V) 3937 283 259 343 130 222 757 508 419 430 336 200 50 Kiryas Joel(V) 7437 1315 1362 2005 702 336 531 818 97 71 139 53 8 Maybrook(V) 2802 306 260 311 121 161 617 437 213 132 140 85 19 Monroe(V) 6672 504 494 849 283 302 975 1208 850 567 355 228 57 Montgomery(V) 2696 209 227 355 114 136 441 475 287 181 167 83 21 Otisville(V) 1078 104 99 148 38 52 187 153 98 77 67 48 7 Tuxedo Park(V) 706 43 33 71 14 35 74 127 129 99 48 28 5 Unionville(V) 548 56 45 55 20 29 101 93 49 39 33 24 4 Walden(V) 5836 476 506 690 238 309 1065 898 519 432 386 239 78 Warwick(V) 5984 555 452 592 198 228 1133 1004 537 450 442 300 93 Washingtonville(V) 4906 543 435 568 129 176 1169 869 389 269 220 109 30 Town totals include villages Source: US Bureau of the Census 1990 Exhibit 1A. 5b 52

PERCENTAGE CHANGE OF AGE DISTRIBUTION BY MUNICIPALITY, ORANGE COUNTY, 1990-2000 A. Age Distribution Percentage Change Municipalities Total 0-4 5-9 10-17 18-20 21-24 25-34 35-44 45-54 55-64 65-74 75-84 85+ Orange County 11.0 1.3 17.7 26.9-5.1-14.5-18.5 19.1 48.9 20.9 0.4 15.4 42.9 Blooming Grove (T) 4.1-15.9 15.9 33.9-3.5-21.4-34.8 6.3 30.2 20.4 8.7 38.0 37.9 Chester (T) 32.9 16.2 48.0 29.3-14.0-30.7-13.0 65.5 85.8 62.8 39.9 31.9 97.7 Cornwall (T) 9.2-1.4 19.4 32.2-17.0-39.6-21.8 13.7 56.9 9.1-4.4 15.1 22.2 Crawford (T) 23.2 1.5 36.2 51.6-8.0-31.4-11.1 30.0 62.8 50.3 17.9 2.6 40.7 Deerpark (T) 0.3-23.0-8.6 21.1-13.7-28.2-32.4 12.5 27.3 36.4-10.5 7.0 36.2 Goshen (T) 12.3 1.8 25.2 15.4-22.8-17.8-16.7 12.3 33.4 28.0 17.7 32.4 86.8 Greenville (T) 21.8 8.0 18.2 39.4 5.5-15.5-9.6 19.9 58.2 65.2 10.3 11.5 39.3 Hamptonburgh (T) 19.8 20.2 14.9 28.7-2.5-20.0-19.0 22.5 54.3 52.5 24.1 15.0 3.0 Highlands (T) -8.7-2.3 6.7 2.5-23.3-14.1-23.9 8.8 21.7-18.4-4.1 1.1 25.0 Middletown (C) 5.1-2.8 12.4 24.0 0.9-16.9-13.4 14.9 50.8 8.6-22.3-2.1 7.5 Minisink (T) 20.3-12.9 16.9 43.2-4.8-24.6-17.0 39.3 62.6 51.4 11.9 10.8 41.7 Monroe (T) 36.3 53.7 44.6 35.0 50.7 63.4 13.4 16.2 86.9 23.5 9.2 3.6 59.5 Montgomery (T) 12.9-3.2 18.3 33.3-10.4-16.1-16.2 26.4 61.6 16.9-3.6 7.3 16.7 Mount Hope (T) 11.2-19.7 4.8 13.4-9.4-21.9-12.7 34.9 55.8 33.2 14.1-12.3 55.2 Newburgh (C) 6.8 4.3 14.9 27.8 6.9-3.2-8.4 15.6 19.5 6.4-20.0-1.3 36.6 Newburgh (T) 14.6 9.3 29.4 26.4-1.0-22.1-16.9 29.0 38.3 14.1 9.9 35.8 34.5 New Windsor (T) -0.3-21.5-2.6 19.5-8.8-22.3-33.0 11.6 46.9 7.4-5.8 21.1 58.5 Port Jervis (C) -2.2-16.1-7.6 20.6-10.0-17.4-27.5 13.6 40.9-8.3-19.9 10.2 35.4 Tuxedo (T) 10.3 9.9 31.9 25.0-9.4-40.6-18.5 22.9 40.0 25.4-4.7-0.7-53.2 Wallkill (T) 7.1-6.7 6.2 7.7-20.4-16.4-13.2 3.0 47.4 41.4 1.3 27.6 79.8 Warwick (T) 13.1-11.8 17.7 38.8-13.1-29.8-32.6 27.8 63.6 25.7 16.0 31.4 90.7 Wawayanda (T) 13.7-9.5 5.7 32.8-1.9-13.5-22.4 20.0 60.6 26.6 2.6 41.7 24.2 Woodbury (T) 14.9 7.9 21.6 28.1-15.0-33.0-19.2 21.0 38.7 49.7 46.7 5.9 46.3 B. Age Distribution Percentage Change Villages Total 0-4 5-9 10-17 18-20 21-24 25-34 35-44 45-54 55-64 65-74 75-84 85+ Chester (V) 5.4-20.9 19.2 37.3-13.5-21.9-31.7 34.3 65.7 23.9 13.8 12.4 84.2 Cornwall on Hudson (V) -1.1-3.3 16.9 16.6-11.9-43.8-24.6 3.7 27.9 6.2-34.3-3.7 33.3 Florida (V) 3.0-22.7 3.2 25.4-6.4-16.5-28.7 9.2 49.1 10.2-8.9 20.6 47.6 Goshen (V) 8.0-12.0 13.2 27.3-7.3-19.9-19.2 3.8 25.4 11.9 7.3 53.0 143.7 Greenwood Lake (V) 6.3-33.0 1.2 60.4-14.2-28.6-34.2 46.1 53.7 19.1-9.0 6.5-3.0 Harriman (V) -1.6-36.0 20.6 61.0 7.4-37.5-45.9 42.2 84.0 23.8 4.0-23.0 76.9 Highland Falls -6.6-26.9-3.9 24.5-13.1-33.8-32.9 21.7 21.2-24.4-9.2 2.0 34.0 Kiryas Joel (V) 76.7 103.6 60.1 34.7 67.8 222.3 172.9-11.4 781.4 22.5-38.1 81.1 175.0 Maybrook (V) 10.1-23.2 3.1 62.1 0.0-17.4-31.9 35.2 95.8 27.3-25.7 11.8 47.4 Monroe (V) 16.6 10.7 39.9 22.0-11.7-18.2-6.5 23.9 39.3 18.7 18.0 1.8 42.1 Montgomery (V) 34.9 23.9 40.1 33.8-12.3-6.6 17.5 40.0 80.1 65.7 15.6 61.4 42.9 Otisville (V) -8.3-47.1-34.3 7.4 15.8-17.3-44.9 9.2 66.3 7.8-9.0-39.6 142.9 Tuxedo Park (V) 3.5 4.7 48.5-4.2 14.3-40.0-21.6-11.8 23.3 15.2 12.5 3.6 20.0 Unionville (V) -2.2-39.3-11.1 21.8-30.0-37.9-40.6 18.3 71.4 38.5-21.2-8.3 75.0 Walden (V) 5.6-6.7 8.5 25.7-4.2-11.7-20.3 21.4 54.5 0.5-12.7-5.9-15.4 Warwick (V) 7.2-27.0 11.7 31.3-19.2-22.4-41.2 12.4 69.5 11.8 11.3 53.3 146.2 Washingtonville (V) 19.3-18.6 27.8 55.6 62.8-8.0-45.2 39.0 110.0 43.5 29.1 88.1 86.7 Source: US Bureau of the Census Exhibit 1A. 5c 53

ORANGE COUNTY POPULATION BY GENDER AND AGE, 2000 Number Percent Age Total Male Female % Male % Female Total Population 341,367 170,965 170,402 50.1 49.9 Under 5 years 25,970 13,439 12,531 51.7 48.3 5 to 9 years 28,746 14,886 13,860 51.8 48.2 10 to 14 years 28,599 14,796 13,803 51.7 48.3 15 to 19 years 25,554 13,810 11,744 54.0 46.0 20 to 24 years 19,938 11,080 8,858 55.6 44.4 25 to 34 years 43,419 21,559 21,860 49.7 50.3 35 to 44 years 59,099 29,866 29,233 50.5 49.5 45 to 54 years 47,221 23,725 23,496 50.2 49.8 55 to 64 years 27,636 13,717 13,919 49.6 50.4 65 to 74 years 18,256 8,220 10,036 45.0 55.0 75 to 84 years 12,294 4,560 7,734 37.1 62.9 85 + 4,635 1,307 3,328 28.2 71.8 Median age (years) 34.7 33.4 Source: US Bureau of the Census, 2000 Exhibit 1A.6 54

ORANGE COUNTY POPULATION MAP BY MUNICIPALITY, AGE, RACE AND ETHNICITY, 1990 AND 2000 Exhibit 1A.7a 55

Exhibit 1A.7b 56

http://www.orangecountygov.com/documentview.asp?sessionid=caaiibbajcbcejjjjia&docid=5281 Exhibit 1A.7b 57

ORANGE COUNTY MUNICIPAL POPULATION BY SINGLE RACE AND YEAR, 1990-2000 Total Population White Black American Indian/ Alaskan Asian, Hawaiian/Pacific Islander Other Race Municipalities 2000 2000 1990 % Change 2000 1990 % Change 2000 1990 % Change 2000 1990 % Change 2000 1990 % Change Orange County 341367 285721 273600 4.4 27601 22223 24.2 1205 824 46.2 5280 3549 48.8 21560 7451 189.4 Blooming Grove (T) 17351 15658 15219 2.9 659 1001-34.2 85 28 203.6 248 211 17.5 701 214 227.6 Chester (T) 12140 10584 8650 22.4 804 272 195.6 41 32 28.1 329 113 191.2 382 71 438.0 Cornwall (T) 12307 11652 10993 6.0 162 110 47.3 20 12 66.7 164 118 39.0 309 37 735.1 Crawford (T) 7875 7528 6249 20.5 94 77 22.1 6 3 100.0 61 32 90.6 186 33 463.6 Deerpark (T) 7858 7506 7549-0.6 121 169-28.4 21 18 16.7 45 35 28.6 165 61 170.5 Goshen (T) 12913 11452 10389 10.2 868 825 5.2 21 37-43.2 226 129 75.2 346 120 188.3 Greenville (T) 3800 3615 3011 20.1 48 47 2.1 11 7 57.1 41 29 41.4 85 26 226.9 Hamptonburgh (T) 4686 4387 3740 17.3 92 79 16.5 9 24-62.5 69 40 72.5 129 27 377.8 Highlands (T) 12484 10259 11894-13.7 1143 1136 0.6 61 36 69.4 354 393-9.9 667 208 220.7 Middletown (C) 25388 17437 19853-12.2 3840 2684 43.1 190 126 50.8 436 342 27.5 3485 1155 201.7 Minisink (T) 3585 3440 2943 16.9 51 19 168.4 1 3-66.7 23 11 109.1 70 5 1300.0 Monroe (T) 31407 29809 22525 32.3 382 135 183.0 80 26 207.7 429 263 63.1 707 86 722.1 Montgomery (T) 20891 19069 17831 6.9 771 361 113.6 53 44 20.5 145 109 33.0 853 156 446.8 Mount Hope (T) 6639 5220 4876 7.1 1096 949 15.5 18 18 0.0 100 54 85.2 205 74 177.0 Newburgh (C) 28259 11962 13557-11.8 9314 9208 1.2 201 91 120.9 231 136 69.9 6551 3462 89.2 Newburgh (T) 27568 23455 22300 5.2 2083 1034 101.5 41 35 17.1 576 363 58.7 1413 326 333.4 New Windsor (T) 22866 19372 20950-7.5 1545 1231 25.5 62 46 34.8 408 341 19.6 1479 369 300.8 Port Jervis (C) 8860 7956 8674-8.3 399 203 96.6 52 33 57.6 59 53 11.3 394 97 306.2 Tuxedo (T) 3334 3090 2961 4.4 41 18 127.8 11 0 107 34 214.7 85 10 750.0 Wallkill (T) 24659 19899 20591-3.4 2304 1356 69.9 75 66 13.6 602 402 49.8 1779 601 196.0 Warwick (T) 30764 28015 25592 9.5 1387 1108 25.2 96 110-12.7 277 152 82.2 989 231 328.1 Wawayanda (T) 6273 5825 5309 9.7 110 88 25.0 23 12 91.7 102 69 47.8 213 40 432.5 Woodbury (T) 9460 8531 7944 7.4 287 113 154.0 27 17 58.8 248 120 106.7 367 42 773.8 Source: US Bureau of the Census; 1990 and 2000 Exhibit 1A.8 58

ORANGE COUNTY POPULATION BY MUNICIPALITY AND HISPANIC ORIGIN: 2000 Total Hispanic or Latino: Total Non- Hispanic or Latino: Black or African/American alone Non-Hispanic American Indian and Alaska Native alone Native Hawaiian and Other Pacific Islander alone White Asian Municipality Total alone alone Orange County 341367 39738 301629 264760 25567 798 5054 85 507 4858 Blooming Grove (T) 17,351 1,556 15,795 14,646 599 76 235 3 26 210 Chester (T) 12,140 1,231 10,909 9,669 768 41 319 6 11 95 Cornwall (T) 12,307 629 11,678 11,226 144 13 150 6 11 128 Crawford (T) 7,875 404 7,471 7,240 89 4 57 1 7 73 Deerpark (T) 7,858 300 7,558 7,297 117 18 45 0 5 76 Goshen (T) 12,913 950 11,963 10,838 801 14 219 5 12 74 Greenville (T) 3,800 170 3,630 3,507 47 4 40 1 1 30 Hamptonburgh (T) 4,686 207 4,479 4,245 88 9 69 0 5 63 Highlands (T) 12,484 962 11,522 9,761 1,064 51 324 19 22 281 Middletown city 25,388 6,375 19,013 14,423 3,350 99 423 3 91 624 Minisink (T) 3,585 165 3,420 3,341 37 1 21 0 1 19 Monroe (T) 31,407 1,543 29,864 28,748 369 50 425 1 37 234 Montgomery (T) 20,891 1,620 19,271 18,138 694 37 137 3 30 232 Mount Hope (T) 6,639 970 5,669 4,514 989 17 97 1 2 49 Newburgh city 28,259 10,257 18,002 7,969 8,961 80 202 3 42 745 Newburgh (T) 27,568 2,644 24,924 22,045 1,873 35 557 7 36 371 New Windsor (T) 22,866 2,538 20,328 18,047 1,446 53 389 7 34 352 Port Jervis city 8,860 660 8,200 7,589 333 39 57 1 20 161 Tuxedo (T) 3,334 142 3,192 2,993 39 11 103 0 5 41 Wallkill (T) 24,659 3,304 21,355 18,020 2,145 50 584 5 48 503 Warwick (T) 30,764 1,991 28,773 26,825 1,234 71 259 10 44 330 Wawayanda (T) 6,273 369 5,904 5,606 107 11 101 1 9 69 Woodbury (T) 9,460 751 8,709 8,073 273 14 241 2 8 98 Chester (V) 3,445 350 3,095 2,653 256 32 98 0 4 52 Cornwall on Hudson (V) 3,058 116 2,942 2,883 7 4 19 1 2 26 Florida (V) 2,571 167 2,404 2,288 55 13 16 0 9 23 Goshen (V) 5,676 433 5,243 4,697 416 5 88 4 2 31 Greenwood Lake (V) 3,411 172 3,239 3,129 22 7 29 0 9 43 Harriman (V) 2,252 223 2,029 1,698 103 7 163 0 10 48 Highland Falls (V) 3,678 389 3,289 2,668 434 13 77 7 6 84 Kiryas Joel (V) 13,138 122 13,016 12,921 26 0 3 0 0 66 Maybrook (V) 3,084 393 2,691 2,333 255 6 37 0 5 55 Monroe (V) 7,780 679 7,101 6,622 197 25 182 1 3 71 Montgomery (V) 3,636 281 3,355 3,142 142 3 29 0 11 28 Otisville (V) 989 66 923 838 59 3 6 0 0 17 Tuxedo Park (V) 731 37 694 658 5 1 13 0 0 17 Unionville (V) 536 44 492 485 2 0 0 0 1 4 Walden (V) 6,164 576 5,588 5,264 200 13 36 1 6 68 Warwick (V) 6,412 364 6,048 5,710 191 6 40 2 5 94 Washingtonville (V) 5,851 660 5,191 4,727 298 10 80 0 13 63 Source: US Bureau of the Census; 2000 Prepared by: Gregg Eriksen, Kathy V. Murphy, Orange County Department of Planning Exhibit 1A. 9a 59 Some other race alone Two or more races

ORANGE COUNTY POPULATION BY MUNICIPALITY AND HISPANIC ORIGIN, 1990 Non-Hispanic 1990 American Indian, Eskimo, or Aleut Asian or Pacific Islander Municipalities Total Population Total Non- Hispanic Total Hispanic White Black Other race Orange County 307647 286112 21535 260968 20731 702 3448 263 Blooming Grove (T) 16673 15730 943 14568 909 27 210 16 Chester (T) 9138 8695 443 8312 241 28 111 3 Cornwall (T) 11270 11008 262 10768 108 12 116 4 Crawford (T) 6394 6202 192 6099 70 3 28 2 Deerpark (T) 7832 7559 273 7349 154 18 35 3 Goshen (T) 11500 10984 516 10029 780 31 127 17 Greenville (T) 3120 3015 105 2937 41 6 29 2 Hamptonburgh (T) 3910 3789 121 3653 71 24 40 1 Highlands (T) 13667 13005 662 11461 1118 36 379 11 Middletown city 24160 20943 3217 18057 2418 109 336 23 Minisink (T) 2981 2900 81 2868 18 3 11 0 Monroe (T) 23035 22363 672 21945 128 25 259 6 Montgomery (T) 18501 17845 656 17345 348 37 108 7 Mount Hope (T) 5971 5191 780 4366 758 11 51 5 Newburgh city 26454 20311 6143 11196 8876 53 122 64 Newburgh (T) 24058 22746 1312 21375 978 29 350 14 New Windsor (T) 22937 21693 1244 20122 1185 45 326 15 Port Jervis city 9060 8677 383 8399 193 27 50 8 Tuxedo (T) 3023 2979 44 2925 18 0 34 2 Wallkill (T) 23016 21247 1769 19492 1263 63 393 36 Warwick (T) 27193 25903 1290 24784 859 93 147 20 Wawayanda (T) 5518 5356 162 5193 87 9 66 1 Woodbury (T) 8236 7971 265 7725 110 13 120 3 Chester (V) 3270 3094 176 2897 125 24 45 3 Cornwall on Hudson (V) 3093 3032 61 2987 10 8 25 2 Florida (V) 2497 2392 105 2313 44 17 17 1 Goshen (V) 5255 5050 205 4615 363 21 47 4 Greenwood Lake (V) 3208 3100 108 3077 4 4 12 3 Harriman (V) 2288 2178 110 2065 55 2 56 0 Highland Falls (V) 3937 3704 233 3111 526 5 56 6 Kiryas Joel (V) 7437 7313 124 7295 2 10 5 1 Maybrook (V) 2802 2646 156 2479 155 2 9 1 Monroe (V) 6672 6384 288 6177 55 4 144 4 Montgomery (V) 2696 2604 92 2537 40 2 23 2 Otisville (V) 1078 1031 47 952 67 4 7 1 Tuxedo Park (V) 706 690 16 682 8 0 0 0 Unionville (V) 548 515 33 514 1 0 0 0 Walden (V) 5836 5598 238 5469 64 14 49 2 Warwick (V) 5984 5764 220 5465 213 43 36 7 Washingtonville (V) 4906 4620 286 4301 225 13 68 13 Source: US Bureau of the Census Exhibit 1A. 9b 60

PERCENTAGE CHANGE OF MUNICIPAL POPULATION BY HISPANIC ORIGIN: ORANGE COUNTY 1990-2000 Percentage Change Hispanic Total Non- Hispanic or Latino 2000 Municipalities Total Persons 2000 Total Hispanic or Latino 2000 Total Hispanic Origin 1999 Total Non- Hispanic 1999 %Change Non- Hispanic Orange County 341367 39738 21535 84.5 301629 286112 5.4 Blooming Grove (T) 17,351 1,556 943 65.0 15,795 15730 0.4 Chester (T) 12,140 1,231 443 177.9 10,909 8695 25.5 Cornwall (T) 12,307 629 262 140.1 11,678 11008 6.1 Crawford (T) 7,875 404 192 110.4 7,471 6202 20.5 Deerpark (T) 7,858 300 273 9.9 7,558 7559 0.0 Goshen (T) 12,913 950 516 84.1 11,963 10984 8.9 Greenville (T) 3,800 170 105 61.9 3,630 3015 20.4 Hamptonburgh (T) 4,686 207 121 71.1 4,479 3789 18.2 Highlands (T) 12,484 962 662 45.3 11,522 13005-11.4 Middletown city 25,388 6,375 3217 98.2 19,013 20943-9.2 Minisink (T) 3,585 165 81 103.7 3,420 2900 17.9 Monroe (T) 31,407 1,543 672 129.6 29,864 22363 33.5 Montgomery (T) 20,891 1,620 656 147.0 19,271 17845 8.0 Mount Hope (T) 6,639 970 780 24.4 5,669 5191 9.2 Newburgh city 28,259 10,257 6143 67.0 18,002 20311-11.4 Newburgh (T) 27,568 2,644 1312 101.5 24,924 22746 9.6 New Windsor (T) 22,866 2,538 1244 104.0 20,328 21693-6.3 Port Jervis city 8,860 660 383 72.3 8,200 8677-5.5 Tuxedo (T) 3,334 142 44 222.7 3,192 2979 7.2 Wallkill (T) 24,659 3,304 1769 86.8 21,355 21247 0.5 Warwick (T) 30,764 1,991 1290 54.3 28,773 25903 11.1 Wawayanda (T) 6,273 369 162 127.8 5,904 5356 10.2 Woodbury (T) 9,460 751 265 183.4 8,709 7971 9.3 Chester (V) 3,445 350 176 98.9 3,095 3094 0.0 Cornwall on Hudson (V) 3,058 116 61 90.2 2,942 3032-3.0 Florida (V) 2,571 167 105 59.0 2,404 2392 0.5 Goshen (V) 5,676 433 205 111.2 5,243 5050 3.8 Greenwood Lake (V) 3,411 172 108 59.3 3,239 3100 4.5 Harriman (V) 2,252 223 110 102.7 2,029 2178-6.8 Highland Falls (V) 3,678 389 233 67.0 3,289 3704-11.2 Kiryas Joel (V) 13,138 122 124-1.6 13,016 7313 78.0 Maybrook (V) 3,084 393 156 151.9 2,691 2646 1.7 Monroe (V) 7,780 679 288 135.8 7,101 6384 11.2 Montgomery (V) 3,636 281 92 205.4 3,355 2604 28.8 Otisville (V) 989 66 47 40.4 923 1031-10.5 Tuxedo Park (V) 731 37 16 131.3 694 690 0.6 Unionville (V) 536 44 33 33.3 492 515-4.5 Walden (V) 6,164 576 238 142.0 5,588 5598-0.2 Warwick (V) 6,412 364 220 65.5 6,048 5764 4.9 Washingtonville (V) 5,851 660 286 130.8 5,191 4620 12.4 Source: US Census Bureau; 1990-2000 Exhibit 1A. 9c 61

WHITE POPULATION BY AGE AND MUNICIPALITY, ORANGE COUNTY 2000 Total Age Municipalities Population Under 5 4-9 10-17 18-20 21-24 25-34 35-44 45-54 55-59 65-74 75-84 85+ Orange County 285721 20514 22905 35806 11540 12105 34779 49647 41235 24508 16662 11607 4413 Blooming Grove (T) 15658 1083 1350 2177 509 505 1792 3035 2451 1411 760 475 110 Chester (T) 10584 780 870 1229 290 325 1324 2186 1762 937 538 261 82 Cornwall (T) 11652 758 934 1495 314 283 1282 2159 1889 1052 774 548 164 Crawford (T) 7528 504 632 1127 239 211 853 1416 1162 665 403 233 83 Deerpark (T) 7506 469 581 984 218 253 859 1353 1125 832 463 292 77 Goshen (T) 11452 621 867 1300 332 405 1279 1897 1644 1049 721 713 624 Greenville (T) 3615 239 312 528 128 104 398 696 580 310 169 112 39 Hamptonburgh (T) 4387 287 363 615 140 136 379 826 752 406 237 148 98 Highlands (T) 10259 724 705 829 1672 1605 1291 1447 889 429 357 238 73 Middletown city 17437 1103 1111 1761 643 816 2639 2723 2392 1515 1188 1102 444 Minisink (T) 3440 218 286 502 116 104 380 693 531 318 157 101 34 Monroe (T) 29809 3875 3555 4982 1910 1613 3440 3844 3322 1502 986 580 200 Montgomery (T) 19069 1267 1579 2594 630 728 2445 3450 2718 1540 1104 763 251 Mount Hope (T) 5220 257 355 625 165 211 765 1124 857 440 259 120 42 Newburgh city 11962 903 811 1259 798 788 1692 1636 1289 916 817 750 303 Newburgh (T) 23455 1444 1669 2546 688 782 2839 4198 3550 2460 1787 1129 363 New Windsor (T) 19372 1249 1390 2186 567 740 2472 3478 2843 1747 1391 1003 306 Port Jervis city 7956 541 562 985 287 356 1022 1224 1012 664 619 492 192 Tuxedo (T) 3090 162 201 281 68 79 352 583 562 422 215 136 29 Wallkill (T) 19899 1191 1332 2257 631 843 2718 3336 3130 1997 1228 872 364 Warwick (T) 28015 1780 2216 3569 765 802 2935 5555 4500 2576 1746 1155 416 Wawayanda (T) 5825 380 468 828 189 162 633 1117 956 518 336 197 41 Woodbury (T) 8531 679 756 1147 241 254 990 1671 1319 802 407 187 78 Source: U.S. Census Bureau 2000 Exhibit 1A. 10a 62

WHITE POPULATION BY MUNICIPALITY AND AGE, ORANGE COUNTY 1990 Municipalities Total Population Under 5 5-9 10-17 18-20 21-24 Age 25-34 35-44 45-54 55-59 65-74 75-84 85+ Orange County 273600 22308 21276 30518 13027 15346 46697 44326 28464 21061 17187 10248 3142 Blooming Grove (T) 15219 1390 1229 1730 567 682 2850 2700 1836 1117 690 345 83 Chester (T) 8650 710 627 1013 351 489 1634 1493 1078 619 393 200 43 Cornwall (T) 10993 807 809 1181 388 485 1700 1956 1219 997 836 480 135 Crawford (T) 6249 506 480 764 271 323 990 1107 721 455 344 229 59 Deerpark (T) 7549 624 640 830 260 361 1296 1198 890 597 516 280 57 Goshen (T) 10389 635 692 1206 454 536 1560 1740 1256 814 636 534 326 Greenville (T) 3011 228 279 381 124 124 452 583 364 195 152 101 28 Hamptonburgh (T) 3740 249 325 486 153 175 487 687 490 266 195 130 97 Highlands (T) 11894 800 720 899 2270 1942 1847 1431 723 556 393 255 58 Middletown city 19853 1567 1341 1791 816 1288 3712 2837 1738 1533 1650 1153 427 Minisink (T) 2943 268 260 363 124 140 483 507 330 210 141 93 24 Monroe (T) 22525 2583 2538 3827 1283 1001 3131 3470 1824 1244 923 576 125 Montgomery (T) 17831 1441 1429 2065 747 940 3096 2879 1765 1359 1168 720 222 Mount Hope (T) 4876 350 348 566 176 262 966 912 556 343 237 131 29 Newburgh city 13557 982 968 1234 830 925 2356 1761 1113 1101 1227 828 232 Newburgh (T) 22300 1548 1474 2291 792 1120 3778 3511 2697 2287 1671 848 283 New Windsor (T) 20950 1802 1600 2039 704 1044 4078 3337 2011 1732 1563 842 198 Port Jervis city 8674 774 691 870 339 488 1500 1149 736 743 793 452 139 Tuxedo (T) 2961 167 160 246 83 137 473 503 423 333 236 138 62 Wallkill (T) 20591 1555 1527 2401 903 1132 3546 3573 2257 1517 1269 704 207 Warwick (T) 25592 2210 2011 2690 888 1146 4564 4552 2825 2065 1537 883 221 Wawayanda (T) 5309 437 470 659 194 200 856 961 598 422 336 143 33 Woodbury (T) 7944 675 658 986 310 406 1342 1479 1014 556 281 183 54 Source: US Census Bureau, 1990 Exhibit 1A. 10b 63

PERCENT CHANGE: WHITE POPULATION BY MUNICIPALITY AND AGE, ORANGE COUNTY 1990-2000 Total Population Age Distribution Percentage Change Municipalities % Change Under 5 5-9 10-17 18-20 21-24 25-34 35-44 45-54 55-59 65-74 75-84 85+ Orange County 4.4-8.0 7.7 17.3-11.4-21.1-25.5 12.0 44.9 16.4-3.1 13.3 40.5 Blooming Grove (T) 2.9-22.1 9.8 25.8-10.2-26.0-37.1 12.4 33.5 26.3 10.1 37.7 32.5 Chester (T) 22.4 9.9 38.8 21.3-17.4-33.5-19.0 46.4 63.5 51.4 36.9 30.5 90.7 Cornwall (T) 6.0-6.1 15.5 26.6-19.1-41.6-24.6 10.4 55.0 5.5-7.4 14.2 21.5 Crawford (T) 20.5-0.4 31.7 47.5-11.8-34.7-13.8 27.9 61.2 46.2 17.2 1.7 40.7 Deerpark (T) -0.6-24.8-9.2 18.6-16.2-29.9-33.7 12.9 26.4 39.4-10.3 4.3 35.1 Goshen (T) 10.2-2.2 25.3 7.8-26.9-24.4-18.0 9.0 30.9 28.9 13.4 33.5 91.4 Greenville (T) 20.1 4.8 11.8 38.6 3.2-16.1-11.9 19.4 59.3 59.0 11.2 10.9 39.3 Hamptonburgh (T) 17.3 15.3 11.7 26.5-8.5-22.3-22.2 20.2 53.5 52.6 21.5 13.8 1.0 Highlands (T) -13.7-9.5-2.1-7.8-26.3-17.4-30.1 1.1 23.0-22.8-9.2-6.7 25.9 Middletown city -12.2-29.6-17.2-1.7-21.2-36.6-28.9-4.0 37.6-1.2-28.0-4.4 4.0 Minisink (T) 16.9-18.7 10.0 38.3-6.5-25.7-21.3 36.7 60.9 51.4 11.3 8.6 41.7 Monroe (T) 32.3 50.0 40.1 30.2 48.9 61.1 9.9 10.8 82.1 20.7 6.8 0.7 60.0 Montgomery (T) 6.9-12.1 10.5 25.6-15.7-22.6-21.0 19.8 54.0 13.3-5.5 6.0 13.1 Mount Hope (T) 7.1-26.6 2.0 10.4-6.3-19.5-20.8 23.2 54.1 28.3 9.3-8.4 44.8 Newburgh city -11.8-8.0-16.2 2.0-3.9-14.8-28.2-7.1 15.8-16.8-33.4-9.4 30.6 Newburgh (T) 5.2-6.7 13.2 11.1-13.1-30.2-24.9 19.6 31.6 7.6 6.9 33.1 28.3 New Windsor (T) -7.5-30.7-13.1 7.2-19.5-29.1-39.4 4.2 41.4 0.9-11.0 19.1 54.5 Port Jervis city -8.3-30.1-18.7 13.2-15.3-27.0-31.9 6.5 37.5-10.6-21.9 8.8 38.1 Tuxedo (T) 4.4-3.0 25.6 14.2-18.1-42.3-25.6 15.9 32.9 26.7-8.9-1.4-53.2 Wallkill (T) -3.4-23.4-12.8-6.0-30.1-25.5-23.4-6.6 38.7 31.6-3.2 23.9 75.8 Warwick (T) 9.5-19.5 10.2 32.7-13.9-30.0-35.7 22.0 59.3 24.7 13.6 30.8 88.2 Wawayanda (T) 9.7-13.0-0.4 25.6-2.6-19.0-26.1 16.2 59.9 22.7 0.0 37.8 24.2 Woodbury (T) 7.4 0.6 14.9 16.3-22.3-37.4-26.2 13.0 30.1 44.2 44.8 2.2 44.4 Source:US Census Buruea, 1990-2000 Exhibit 1A. 10c 64

HISPANIC OR LATINO POPULATION BY MUNICIPALITY AND AGE, ORANGE COUNTY 2000 Age Municipalities Total Population Under 5 5-9 10-17 18-20 21-24 25-34 35-44 45-54 55-64 65-74 75-84 85+ Orange County 39,738 4,424 4,224 5,858 2,154 2,593 6,999 6,508 3,878 1,759 837 350 154 Blooming Grove (T) 1,556 157 152 269 64 69 208 309 191 68 44 15 10 Chester (T) 1,231 98 95 161 42 22 156 329 244 48 24 9 3 Cornwall (T) 629 62 69 121 27 19 87 116 69 32 21 4 2 Crawford (T) 404 35 47 71 19 26 59 66 41 30 7 2 1 Deerpark (T) 300 37 29 55 14 11 42 42 34 21 13 2 0 Goshen (T) 950 71 92 135 57 68 180 170 85 43 19 17 13 Greenville (T) 170 26 19 29 8 6 20 30 20 7 5 0 0 Hamptonburgh (T) 207 22 25 40 8 6 26 30 26 13 9 1 1 Highlands (T) 962 98 91 107 145 129 161 112 59 33 14 7 6 Middletown city 6,375 787 740 985 404 485 1174 915 486 226 113 47 13 Minisink (T) 165 15 21 31 8 6 24 28 14 15 1 2 0 Monroe (T) 1,543 154 178 250 73 85 231 282 171 68 28 22 1 Montgomery (T) 1,620 187 186 259 86 96 257 291 158 59 28 6 7 Mount Hope (T) 970 28 39 49 18 79 303 277 123 40 13 1 0 Newburgh city 10,257 1388 1161 1390 674 861 2032 1303 752 425 179 67 25 Newburgh (T) 2,644 266 283 452 118 115 375 444 316 149 62 37 27 New Windsor (T) 2,538 266 252 354 109 141 445 445 282 112 90 32 10 Port Jervis city 660 90 80 119 27 34 107 93 39 41 17 8 5 Tuxedo (T) 142 7 14 17 5 6 16 36 27 10 3 1 0 Wallkill (T) 3,304 328 345 491 141 184 569 547 373 194 78 34 20 Warwick (T) 1,991 184 185 279 53 96 355 434 243 81 42 30 9 Wawayanda (T) 369 33 43 72 17 19 50 68 41 16 9 1 0 Woodbury (T) 751 85 78 122 37 30 122 141 84 28 18 5 1 Source: US Census Bureau, 2000 Exhibit 1A. 11a 65

HISPANIC OR LATINO POPULATION BY MUNICIPALITY AND AGE, ORANGE COUNTY 1990 Municipalities Total Population Under 5 5-9 10-17 18-20 21-24 25-34 35-44 45-54 55-64 65-74 75-84 85 + Orange County 21535 2217 2082 3001 1352 1754 4313 3376 1786 942 408 252 52 Blooming Grove (T) 943 79 73 115 21 22 150 225 139 86 22 8 3 Chester (T) 443 24 44 85 28 34 84 66 47 22 7 2 0 Cornwall (T) 262 34 19 39 15 14 45 42 27 14 8 4 1 Crawford (T) 192 24 14 28 16 12 31 31 25 3 5 2 1 Deerpark (T) 273 37 26 47 11 13 46 50 19 20 2 2 0 Goshen (T) 516 43 26 56 47 44 108 95 51 26 8 8 4 Greenville (T) 105 8 8 26 2 5 15 20 11 5 2 2 1 Hamptonburgh (T) 121 14 13 18 4 13 13 18 15 6 5 1 1 Highlands (T) 662 59 44 62 126 121 115 73 35 18 5 4 0 Middletown city 3217 413 340 479 206 310 621 416 201 128 61 36 6 Minisink (T) 81 15 14 8 5 1 12 15 7 1 1 2 0 Monroe (T) 672 70 57 115 45 24 116 131 51 30 23 8 2 Montgomery (T) 656 67 72 122 32 38 140 80 51 28 12 12 2 Mount Hope (T) 780 17 16 21 16 75 329 191 79 24 8 4 0 Newburgh city 6143 716 713 930 455 564 1189 778 423 212 90 64 9 Newburgh (T) 1312 101 140 190 59 94 211 197 161 80 46 23 10 New Windsor (T) 1244 159 122 161 53 83 239 231 82 65 29 17 3 Port Jervis city 383 41 44 63 25 15 71 44 34 17 18 10 1 Tuxedo (T) 44 4 1 7 1 2 8 9 7 4 0 0 1 Wallkill (T) 1769 170 163 252 110 128 304 320 181 83 31 22 5 Warwick (T) 1290 82 93 109 58 105 392 257 108 51 19 15 1 Wawayanda (T) 162 13 16 30 6 13 26 33 10 9 2 4 0 Woodbury (T) 265 27 24 38 11 24 48 54 22 10 4 2 1 Source: US Census Bureau, 1990 Age Exhibit 1A. 11b 66

PERCENTAGE CHANGE: HISPANIC OR LATINO POPULATION BY MUNICIPALITY AND AGE, ORANGE COUNTY 1990-2000 Age Distribution Percentage Change Municipalities Total Population Under 5 5-9 10-17 18-20 21-24 25-34 35-44 45-54 55-64 65-74 75-84 85 and over Orange County 84.5 99.5 102.9 95.2 59.3 47.8 62.3 92.8 117.1 86.7 105.1 38.9 196.2 Blooming Grove (T) 65.0 98.7 108.2 133.9 204.8 213.6 38.7 37.3 37.4-20.9 100.0 87.5 233.3 Chester (T) 177.9 308.3 115.9 89.4 50.0-35.3 85.7 398.5 419.1 118.2 242.9 350.0 N/A Cornwall (T) 140.1 82.4 263.2 210.3 80.0 35.7 93.3 176.2 155.6 128.6 162.5 0.0 100.0 Crawford (T) 110.4 45.8 235.7 153.6 18.8 116.7 90.3 112.9 64.0 900.0 40.0 0.0 0.0 Deerpark (T) 9.9 0.0 11.5 17.0 27.3-15.4-8.7-16.0 78.9 5.0 550.0 0.0 N/A Goshen (T) 84.1 65.1 253.8 141.1 21.3 54.5 66.7 78.9 66.7 65.4 137.5 112.5 225.0 Greenville (T) 61.9 225.0 137.5 11.5 300.0 20.0 33.3 50.0 81.8 40.0 150.0-100.0-100.0 Hamptonburgh (T) 71.1 57.1 92.3 122.2 100.0-53.8 100.0 66.7 73.3 116.7 80.0 0.0 0.0 Highlands (T) 45.3 66.1 106.8 72.6 15.1 6.6 40.0 53.4 68.6 83.3 180.0 75.0 N/A Middletown city 98.2 90.6 117.6 105.6 96.1 56.5 89.0 120.0 141.8 76.6 85.2 30.6 116.7 Minisink (T) 103.7 0.0 50.0 287.5 60.0 500.0 100.0 86.7 100.0 1400.0 0.0 0.0 N/A Monroe (T) 129.6 120.0 212.3 117.4 62.2 254.2 99.1 115.3 235.3 126.7 21.7 175.0-50.0 Montgomery (T) 147.0 179.1 158.3 112.3 168.8 152.6 83.6 263.8 209.8 110.7 133.3-50.0 250.0 Mount Hope (T) 24.4 64.7 143.8 133.3 12.5 5.3-7.9 45.0 55.7 66.7 62.5-75.0 N/A Newburgh city 67.0 93.9 62.8 49.5 48.1 52.7 70.9 67.5 77.8 100.5 98.9 4.7 177.8 Newburgh (T) 101.5 163.4 102.1 137.9 100.0 22.3 77.7 125.4 96.3 86.3 34.8 60.9 170.0 New Windsor (T) 104.0 67.3 106.6 119.9 105.7 69.9 86.2 92.6 243.9 72.3 210.3 88.2 233.3 Port Jervis city 72.3 119.5 81.8 88.9 8.0 126.7 50.7 111.4 14.7 141.2-5.6-20.0 400.0 Tuxedo (T) 222.7 75.0 1300.0 142.9 400.0 200.0 100.0 300.0 285.7 150.0 N/A N/A -100.0 Wallkill (T) 86.8 92.9 111.7 94.8 28.2 43.8 87.2 70.9 106.1 133.7 151.6 54.5 300.0 Warwick (T) 54.3 124.4 98.9 156.0-8.6-8.6-9.4 68.9 125.0 58.8 121.1 100.0 800.0 Wawayanda (T) 127.8 153.8 168.8 140.0 183.3 46.2 92.3 106.1 310.0 77.8 350.0-75.0 N/A Woodbury (T) 183.4 214.8 225.0 221.1 236.4 25.0 154.2 161.1 281.8 180.0 350.0 150.0 0.0 N/A: Null values Source: US Census Bureau Exhibit 1A. 11c 67

ASIAN, HAWAIIAN/PACIFIC ISLANDER POPULATION BY MUNICIPALITY AND AGE, ORANGE COUNTY, 2000 Age Municipalities Total Population 0-4 5-9 10-17 18-20 21-24 25-34 35-44 45-54 55-64 65-74 75-84 85+ Orange County 5280 398 355 677 246 277 802 1008 841 390 198 71 17 Blooming Grove (T) 248 18 24 24 4 11 36 55 42 19 13 1 1 Chester (T) 329 20 15 38 7 10 47 90 70 18 7 7 0 Cornwall (T) 164 14 11 21 3 5 23 30 31 17 9 0 0 Crawford (T) 61 4 7 11 0 1 11 11 6 8 1 1 0 Deerpark (T) 45 2 2 8 2 1 2 10 10 2 4 2 0 Goshen (T) 226 12 12 45 6 5 31 36 42 19 15 3 0 Greenville (T) 41 3 2 4 0 2 5 6 7 9 2 1 0 Hamptonburgh (T) 69 7 5 12 4 2 4 10 18 4 2 1 0 Highlands (T) 354 12 12 16 107 87 39 38 22 11 4 4 2 Middletown city 436 34 30 51 12 25 77 73 74 41 15 4 0 Minisink (T) 23 5 5 0 0 0 6 2 2 0 2 1 0 Monroe (T) 429 35 46 64 9 7 45 98 75 29 12 8 1 Montgomery (T) 145 7 4 23 2 6 22 28 32 15 2 2 2 Mount Hope (T) 100 5 2 5 1 7 43 18 12 7 0 0 0 Newburgh city 231 21 15 28 16 16 39 39 19 15 13 8 2 Newburgh (T) 576 51 47 85 14 23 70 108 96 43 25 10 4 New Windsor (T) 408 27 23 53 13 17 77 77 61 39 15 4 2 Port Jervis city 59 5 2 4 2 4 11 14 8 3 5 0 1 Tuxedo (T) 107 9 5 14 4 3 22 29 13 2 6 0 0 Wallkill (T) 602 54 32 72 32 27 94 114 99 46 23 7 2 Warwick (T) 277 25 29 37 3 10 47 55 43 12 13 3 0 Wawayanda (T) 102 9 8 18 3 1 8 19 18 11 6 1 0 Woodbury (T) 248 19 17 44 2 7 43 48 41 20 4 3 0 Source: US Census Bureau, 2000 Exhibit 1A. 12a 68

ASIAN, HAWAIIAN OR PACIFIC ISLANDER POPULATION BY MUNICIPALITY AND AGE: ORANGE COUNTY,1990 Age Municipalities Total Population 0-4 5-9 10-17 18-20 21-24 25-34 35-44 45-54 55-64 65-74 75-84 85 and over Orange County 3549 292 337 479 277 220 575 694 396 158 89 28 4 Blooming Grove (T) 211 24 24 32 5 5 30 59 20 5 5 2 0 Chester (T) 113 13 8 16 4 3 24 24 11 3 4 3 0 Cornwall (T) 118 9 15 20 5 9 12 23 17 5 1 2 0 Crawford (T) 32 3 4 6 2 1 3 4 8 0 0 1 0 Deerpark (T) 35 3 4 5 2 0 5 10 3 2 1 0 0 Goshen (T) 129 4 17 21 7 4 15 28 17 11 2 2 1 Greenville (T) 29 2 2 5 2 2 4 4 4 2 1 1 0 Hamptonburgh (T) 40 2 7 11 1 0 3 8 4 2 0 1 1 Highlands (T) 393 15 14 31 131 84 47 37 18 8 5 3 0 Middletown city 342 25 38 43 16 14 61 78 36 16 10 5 0 Minisink (T) 11 1 0 1 0 0 2 1 1 3 2 0 0 Monroe (T) 263 21 33 36 15 11 32 53 39 12 8 2 1 Montgomery (T) 109 13 8 13 10 8 21 19 10 3 3 1 0 Mount Hope (T) 54 1 2 6 2 5 12 17 6 2 1 0 0 Newburgh city 136 12 12 11 5 5 42 27 14 7 1 0 0 Newburgh (T) 363 26 40 63 8 20 58 71 46 17 13 1 0 New Windsor (T) 341 39 29 38 14 16 76 68 34 17 7 3 0 Port Jervis city 53 4 7 6 1 2 12 4 8 8 1 0 0 Tuxedo (T) 34 2 3 6 2 1 6 7 4 3 0 0 0 Wallkill (T) 402 31 39 62 23 20 59 86 56 14 11 0 1 Warwick (T) 152 21 9 16 10 8 29 31 15 6 6 1 0 Wawayanda (T) 69 5 8 12 7 0 3 18 10 4 2 0 0 Woodbury (T) 120 16 14 19 5 2 19 17 15 8 5 0 0 Source: US Census Bureau, 1990 Exhibit 1A. 12b 69

PERCENTAGE CHANGE IN ASIAN OR PACIFIC ISLANDER POPULATION BY MUNICIPALITY AND AGE, ORANGE COUNTY 1990-2000 Municipalities Total Population 0-4 5-9 10-17 18-20 21-24 25-34 35-44 45-54 55-64 65-74 75-84 85 + Orange County 48.8 36.3 5.3 41.3-11.2 25.9 39.5 45.2 112.4 146.8 122.5 153.6 325.0 Blooming Grove (T) 17.5-25.0 0.0-25.0-20.0 120.0 20.0-6.8 110.0 280.0 160.0-50.0 N/A Chester (T) 191.2 53.8 87.5 137.5 75.0 233.3 95.8 275.0 536.4 500.0 75.0 133.3 N/A Cornwall (T) 39.0 55.6-26.7 5.0-40.0-44.4 91.7 30.4 82.4 240.0 800.0-100.0 N/A Crawford (T) 90.6 33.3 75.0 83.3-100.0 0.0 266.7 175.0-25.0 N/A N/A 0.0 N/A Deerpark (T) 28.6-33.3-50.0 60.0 0.0 N/A -60.0 0.0 233.3 0.0 300.0 N/A N/A Goshen (T) 75.2 200.0-29.4 114.3-14.3 25.0 106.7 28.6 147.1 72.7 650.0 50.0-100.0 Greenville (T) 41.4 50.0 0.0-20.0-100.0 0.0 25.0 50.0 75.0 350.0 100.0 0.0 N/A Hamptonburgh (T) 72.5 250.0-28.6 9.1 300.0 N/A 33.3 25.0 350.0 100.0 N/A 0.0-100.0 Highlands (T) -9.9-20.0-14.3-48.4-18.3 3.6-17.0 2.7 22.2 37.5-20.0 33.3 N/A Middletown city 27.5 36.0-21.1 18.6-25.0 78.6 26.2-6.4 105.6 156.3 50.0-20.0 N/A Minisink (T) 109.1 400.0 N/A -100.0 N/A N/A 200.0 100.0 100.0-100.0 0.0 N/A N/A Monroe (T) 63.1 66.7 39.4 77.8-40.0-36.4 40.6 84.9 92.3 141.7 50.0 300.0 0.0 Montgomery (T) 33.0-46.2-50.0 76.9-80.0-25.0 4.8 47.4 220.0 400.0-33.3 100.0 N/A Mount Hope (T) 85.2 400.0 0.0-16.7-50.0 40.0 258.3 5.9 100.0 250.0-100.0 N/A N/A Newburgh city 69.9 75.0 25.0 154.5 220.0 220.0-7.1 44.4 35.7 114.3 1200.0 N/A N/A Newburgh (T) 58.7 96.2 17.5 34.9 75.0 15.0 20.7 52.1 108.7 152.9 92.3 900.0 N/A New Windsor (T) 19.6-30.8-20.7 39.5-7.1 6.3 1.3 13.2 79.4 129.4 114.3 33.3 N/A Port Jervis city 11.3 25.0-71.4-33.3 100.0 100.0-8.3 250.0 0.0-62.5 400.0 N/A N/A Tuxedo (T) 214.7 350.0 66.7 133.3 100.0 200.0 266.7 314.3 225.0-33.3 N/A N/A N/A Wallkill (T) 49.8 74.2-17.9 16.1 39.1 35.0 59.3 32.6 76.8 228.6 109.1 N/A 100.0 Warwick (T) 82.2 19.0 222.2 131.3-70.0 25.0 62.1 77.4 186.7 100.0 116.7 200.0 N/A Wawayanda (T) 47.8 80.0 0.0 50.0-57.1 N/A 166.7 5.6 80.0 175.0 200.0 N/A N/A Woodbury (T) 106.7 18.8 21.4 131.6-60.0 250.0 126.3 182.4 173.3 150.0-20.0 N/A N/A N/A: Null values Source: US Census Bureau, 1990-2000 Age Exhibit 1A. 12c 70

BLACK / AFRICAN AMERICAN POPULATION BY MUNICIPALITY AND AGE, ORANGE COUNTY 2000 Municipalities Total Population Under 5 5-9 10-17 18-20 21-24 25-34 35-44 45-54 55-64 65-74 75-84 85+ Orange County 27601 2201 2724 19-Sep 1303 1384 3976 5065 3186 1886 1011 434 151 Blooming Grove (T) 659 47 65 119 33 14 75 116 96 41 37 9 7 Chester (T) 804 31 37 120 15 12 55 254 211 52 12 3 2 Cornwall (T) 162 7 15 28 4 4 13 41 13 18 11 7 1 Crawford (T) 94 7 10 11 3 4 11 14 18 11 2 3 0 Deerpark (T) 121 5 6 17 4 5 16 18 18 13 8 9 2 Goshen (T) 868 17 20 124 69 78 144 158 110 62 41 24 21 Greenville (T) 48 5 8 5 2 1 10 7 7 1 0 2 0 Hamptonburgh (T) 92 2 5 10 0 3 7 21 18 12 8 3 3 Highlands (T) 1143 80 95 141 159 147 167 163 64 53 49 21 4 Middletown city 3840 368 408 625 174 205 536 677 423 231 118 55 20 Minisink (T) 51 5 4 10 1 2 3 11 11 3 1 0 0 Monroe (T) 382 27 33 64 13 11 40 94 59 22 15 4 0 Montgomery (T) 771 68 78 146 28 28 98 152 107 38 18 9 1 Mount Hope (T) 1096 21 14 23 13 76 396 347 122 45 29 7 3 Newburgh city 9314 895 1145 1611 507 476 1240 1309 867 699 363 159 43 Newburgh (T) 2083 171 222 332 82 85 242 401 261 173 75 24 15 New Windsor (T) 1545 130 150 253 61 57 233 319 160 102 58 18 4 Port Jervis city 399 50 42 61 12 33 57 69 35 16 15 9 0 Tuxedo (T) 41 2 1 4 1 0 8 5 13 5 1 1 0 Wallkill (T) 2304 171 244 365 75 104 326 410 317 165 76 36 15 Warwick (T) 1387 69 91 130 30 33 266 387 194 91 61 25 10 Wawayanda (T) 110 3 8 24 4 2 11 27 12 10 5 4 0 Woodbury (T) 287 20 23 57 13 4 22 65 50 23 8 2 0 Source: US Census Bureau, 2000 Age Exhibit 1A. 13a 71

BLACK / AFRICAN AMERICAN POPULATION BY MUNICIPALITY AND AGE, ORANGE COUNTY, 1990 Municipalities Total Population Under 5 5-9 10-17 18-20 21-24 25-34 35-44 45-54 55-64 65-74 75-84 85+ Orange County 22223 2186 2015 2830 1252 1526 4315 3370 2211 1344 777 303 94 Blooming Grove (T) 1001 31 43 57 21 11 144 346 182 96 56 10 4 Chester (T) 272 17 17 87 12 12 42 41 25 7 7 5 0 Cornwall (T) 110 12 6 15 8 6 27 15 11 2 6 2 0 Crawford (T) 77 7 6 9 2 5 10 20 8 7 2 1 0 Deerpark (T) 169 18 7 26 4 3 22 29 19 20 16 4 1 Goshen (T) 825 30 30 91 65 66 202 124 77 66 25 28 21 Greenville (T) 47 4 3 3 2 1 12 10 7 1 3 1 0 Hamptonburgh (T) 79 6 1 8 3 4 9 12 17 12 5 1 1 Highlands (T) 1136 87 86 101 202 186 189 93 81 62 36 7 6 Middletown city 2684 300 311 422 132 160 479 368 221 149 86 45 11 Minisink (T) 19 1 1 4 0 0 2 6 4 1 0 0 0 Monroe (T) 135 12 11 18 3 7 26 30 11 9 7 1 0 Montgomery (T) 361 34 45 59 15 12 68 63 36 12 11 6 0 Mount Hope (T) 949 11 22 20 22 111 421 195 84 30 18 15 0 Newburgh city 9208 1241 1008 1252 547 602 1546 1114 852 563 341 110 32 Newburgh (T) 1034 83 98 150 51 53 131 189 150 71 43 11 4 New Windsor (T) 1231 131 121 156 43 82 299 191 121 57 20 8 2 Port Jervis city 203 14 16 32 11 13 40 30 16 13 10 4 4 Tuxedo (T) 18 0 1 0 0 0 4 5 2 6 0 0 0 Wallkill (T) 1356 94 116 227 64 69 241 258 157 66 42 18 4 Warwick (T) 1108 37 42 63 40 112 373 189 104 84 36 24 4 Wawayanda (T) 88 4 12 16 3 1 12 19 12 5 3 1 0 Woodbury (T) 113 12 12 14 2 10 16 23 14 5 4 1 0 Source: US Census Bureau, 1990 Age Exhibit 1A 13b 72

PERCENTAGE CHANGE OF BLACK/AFRICAN AMERICAN POPULATION BY MUNICIPALITY AND AGE ORANGE COUNTY, 1990-2000 Total Municipalities Population Under 5 5-9 10-17 18-20 21-24 25-34 35-44 45-54 55-64 65-74 75-84 85+ Orange County 24.2 0.7 35.2 51.2 4.1-9.3-7.9 50.3 44.1 40.3 30.1 43.2 60.6 Blooming Grove (T) -34.2 51.6 51.2 108.8 57.1 27.3-47.9-66.5-47.3-57.3-33.9-10.0 75.0 Chester (T) 195.6 82.4 117.6 37.9 25.0 0.0 31.0 519.5 744.0 642.9 71.4-40.0 N/A Cornwall (T) 47.3-41.7 150.0 86.7-50.0-33.3-51.9 173.3 18.2 800.0 83.3 250.0 N/A Crawford (T) 22.1 0.0 66.7 22.2 50.0-20.0 10.0-30.0 125.0 57.1 0.0 200.0 N/A Deerpark (T) -28.4-72.2-14.3-34.6 0.0 66.7-27.3-37.9-5.3-35.0-50.0 125.0 100.0 Goshen (T) 5.2-43.3-33.3 36.3 6.2 18.2-28.7 27.4 42.9-6.1 64.0-14.3 0.0 Greenville (T) 2.1 25.0 166.7 66.7 0.0 0.0-16.7-30.0 0.0 0.0-100.0 100.0 N/A Hamptonburgh (T) 16.5-66.7 400.0 25.0-100.0-25.0-22.2 75.0 5.9 0.0 60.0 200.0 200.0 Highlands (T) 0.6-8.0 10.5 39.6-21.3-21.0-11.6 75.3-21.0-14.5 36.1 200.0-33.3 Middletown city 43.1 22.7 31.2 48.1 31.8 28.1 11.9 84.0 91.4 55.0 37.2 22.2 81.8 Minisink (T) 168.4 400.0 300.0 150.0 N/A N/A 50.0 83.3 175.0 200.0 N/A N/A N/A Monroe (T) 183.0 125.0 200.0 255.6 333.3 57.1 53.8 213.3 436.4 144.4 114.3 300.0 N/A Montgomery (T) 113.6 100.0 73.3 147.5 86.7 133.3 44.1 141.3 197.2 216.7 63.6 50.0 N/A Mount Hope (T) 15.5 90.9-36.4 15.0-40.9-31.5-5.9 77.9 45.2 50.0 61.1-53.3 N/A Newburgh city 1.2-27.9 13.6 28.7-7.3-20.9-19.8 17.5 1.8 24.2 6.5 44.5 34.4 Newburgh (T) 101.5 106.0 126.5 121.3 60.8 60.4 84.7 112.2 74.0 143.7 74.4 118.2 275.0 New Windsor (T) 25.5-0.8 24.0 62.2 41.9-30.5-22.1 67.0 32.2 78.9 190.0 125.0 100.0 Port Jervis city 96.6 257.1 162.5 90.6 9.1 153.8 42.5 130.0 118.8 23.1 50.0 125.0-100.0 Tuxedo (T) 127.8 N/A 0.0 N/A N/A N/A 100.0 0.0 550.0-16.7 N/A N/A N/A Wallkill (T) 69.9 81.9 110.3 60.8 17.2 50.7 35.3 58.9 101.9 150.0 81.0 100.0 275.0 Warwick (T) 25.2 86.5 116.7 106.3-25.0-70.5-28.7 104.8 86.5 8.3 69.4 4.2 150.0 Wawayanda (T) 25.0-25.0-33.3 50.0 33.3 100.0-8.3 42.1 0.0 100.0 66.7 300.0 N/A Woodbury (T) 154.0 66.7 91.7 307.1 550.0-60.0 37.5 182.6 257.1 360.0 100.0 100.0 N/A N/A: Null values Source: US Census Bureau, 1990-2000 Age Exhibit 1A.13c 73

NATIVITY AND REGION OF BIRTH, ORANGE COUNTY POPULATION, 2000 NATIVITY, CITIZENSHIP STATUS, AND YEAR OF ENTRY Number Percent Total population 341,367 100 Native 312,657 91.6 Foreign born 28,710 8.4 Naturalized citizen 13,889 48.4 Not a citizen 14,821 51.6 Entered 1990 to March 2000 9,082 31.6 Naturalized citizen 1,014 11.2 Not a citizen 8,068 88.8 Entered 1980 to 1989 6,892 24 Naturalized citizen 2,770 40.2 Not a citizen 4,122 59.8 Entered before 1980 12,736 44.4 Naturalized citizen 10,105 79.3 Not a citizen 2,631 20.7 FOREIGN-BORN POPULATION BY REGION OF BIRTH AND YEAR OF ENTRY* Europe 9,796 100 1990 to March 2000 1,307 13.3 1980 to 1989 1,163 11.9 Before 1980 7,326 74.8 Asia 4,716 100 1990 to March 2000 1,686 35.8 1980 to 1989 1,331 28.2 Before 1980 1,699 36 Africa 436 100 1990 to March 2000 203 46.6 1980 to 1989 121 27.8 Before 1980 112 25.7 Oceania 52 100 1990 to March 2000 19 36.5 1980 to 1989 10 19.2 Before 1980 23 44.2 Latin America 12,991 100 1990 to March 2000 5,715 44 1980 to 1989 4,162 32 Before 1980 3,114 24 Northern America 719 100 1990 to March 2000 152 21.1 1980 to 1989 105 14.6 Before 1980 462 64.3 *Excluding born at sea Source: US Census Bureau, 2000 Exhibit1A.14a 74

FOREIGN-BORN POPULATION BY ZIP CODE, ORANGE COUNTY, HUDSON VALLEY REGION, 1990-2000 Source: New York Medical College School of Public Health, The Health of Recent Immigrants to the Lower Hudson Valley and the Challenges Faced by Those Who Serve Them Exhibit 1A 14b 75

LANGUAGE SPOKEN AT HOME BY MUNICIPALITY, ORANGE COUNTY, 2000 A. Total Language Other Than English Population 5 Speak English Less Other Indo-European Asian and Pacific Island years and Speak English Only than "very well" Spanish Languages Languages Municipalities above Counts Percentage Counts Percentage Counts Percentage Counts Percentage Counts Percentage Orange County 315397 237,031 75 26,519 8 28,137 9 44,544 14 3,164 1 Blooming Grove town 16122 14,289 89 486 3 911 6 655 4 143 1 Chester town 11274 9,535 85 435 4 857 8 595 5 201 2 Cornwall town 11483 10,491 91 217 2 520 5 388 3 87 1 Crawford town 7348 6,683 91 220 3 214 3 383 5 54 1 Deerpark town 7358 6,875 93 162 2 358 5 183 2 0 0 Goshen town 12229 10,466 86 522 4 859 7 690 6 80 1 Greenville town 3544 3,246 92 89 3 142 4 114 3 32 1 Hamptonburgh town 4376 3,974 91 157 4 162 4 20 0 102 2 Highlands town 11596 10,075 87 355 3 711 6 522 5 247 2 Middletown city 23390 16,987 73 2,862 12 4,684 20 1,227 5 154 1 Minisink town 3348 3,036 91 87 3 89 3 9 0 206 6 Monroe town 27373 14,311 52 9,334 34 1,187 4 11,290 41 250 1 Montgomery town 19439 17,560 90 575 3 979 5 777 4 72 0 Mount Hope town 6346 5,775 91 579 9 401 6 18 0 159 3 Newburgh city 25493 16,338 64 4,608 18 8,191 32 863 3 86 0 Newburgh town 25728 22,004 86 1,116 4 1,960 8 1,327 86 334 1 New Windsor town 21274 18,053 85 984 5 1,778 8 1,249 6 127 1 Port Jervis city 8183 7,696 94 150 2 344 4 163 2 45 1 Tuxedo town 3146 2,772 88 136 4 92 3 209 7 86 3 Wallkill town 23038 19,204 83 1,256 5 2,331 10 1,105 5 370 2 Warwick town 28754 25,791 90 809 3 1,275 4 1,278 4 193 1 Wawayanda town 5862 5,207 89 200 3 244 4 407 7 7 0 Woodbury town 8693 7,551 87 336 4 481 6 395 5 129 1 Exhibit 1A.15 76

LANGUAGE SPOKEN AT HOME BY MUNICIPALITY, ORANGE COUNTY, 2000 B. Total Language Other Than English Population 5 Speak English Less Other Indo-European Asian and Pacific Island years and Speak English Only than "very well" Spanish Languages Languages Villages (V) above Counts Percentage Counts Percentage Counts Percentage Counts Percentage Counts Percentage Chester (V) 3210 2,927 91 57 2 255 8 86 3 49 2 Cornwall on Hudson 2883 2,641 92 51 2 122 4 98 3 20 1 Florida (V) 2397 2,118 88 90 4 138 6 138 6 28 1 Goshen (V) 5405 4,667 86 228 4 338 6 262 5 21 0 Greenwood Lake (V) 3196 2,866 90 50 2 112 4 118 4 37 1 Harriman (V) 2097 1,668 80 137 7 193 9 102 5 97 5 Highland Falls (V) 3471 2,936 85 115 3 179 5 254 7 52 1 Kiryas Joel (V) 10461 672 6 7,791 74 121 1 9,502 91 0 0 Maybrook (V) 2849 2,459 86 90 3 266 9 85 3 17 1 Monroe (V) 7222 6,028 83 552 8 497 7 525 7 140 2 Montgomery (V) 3377 2,953 87 61 2 144 4 206 6 31 1 Otisville (V) 934 926 99 15 2 32 3 5 1 2 0 Tuxedo Park (V) 686 577 84 32 5 33 5 45 7 23 3 Unionville (V) 502 421 84 12 2 65 13 22 4 0 0 Walden (V) 5720 5,237 92 224 4 379 7 123 2 0 0 Warwick (V) 6007 5,399 90 180 3 238 4 225 4 53 1 Washingtonville (V) 5409 4,631 86 198 4 401 7 210 4 83 2 Town totals include villages (V) Kiryas Joel was formed in 1977 Exhibit 1A.15 77

LIMITED ENGLISH PROFICIENCY AND ELIGIBILITY FOR FREE REDUCED LUNCH BY SCHOOL DISTRICT, 2007-2008 A. School District Total Number of Students Student Count and % Limited English Proficiency Eligibility for Reduced/Free Lunch Chester Union 992 # of Students 10 192 Chester Elementary School Percent 1.0 19 Chester Junior-Senior High School Cornwall Central 3,320 # of Students 28 286 Cornwall Central High School Percent 1.0 9.0 Cornwall Elementary School Cornwall-On-Hudson Elementary School Willow Avenue Elementary School Florida Union 852 # of Students 21 126 Golden Hill Elementary Percent 2.0 14 Goshen Central 2,900 # of Students 92 334 Goshen Central High School Percent 3.0 11 C.J. Hooker Middle School Scotchtown Avenue School Goshen Intermediate School S.S. Seward Institute Greenwood Lake Union 596 # of Students 3.0 92 Greenwood Lake Elementary School Percent 1.0 15 Greenwood Lake Middle School Highlands Falls Central 1,160 # of Students 47 252 Highland Falls Elementary School Percent 4.0 22 Highland Falls Middle School Fort Montgomery Elementary School James I. O'Neill High School Kiryas Joel Village 217 # of Students 72 192 Kiryas Joel Village School Percent 33 88 Middletown City 6,596 # of Students 779 4,429 Maple Hill Elementary School Percent 12 67 Mechanicstown School Memorial Education Center Middletown High School Middletown Twin Towers Middle School John W. Chorley School Monhagen Middle School Truman Moon School Minisink Valley Central 4,661 # of Students 31 777 Minisink Valley Elementary School Percent 1.0 17 Minisink Valley High School Minisink Valley Intermediate School Minisink Valley Middle School Otisville Elementary School Exhibit 1A. 16a 78

LIMITED ENGLISH PROFICIENCY AND ELIGIBILITY FOR FREE REDUCED LUNCH BY SCHOOL DISTRICT, 2007-2008 School District Total Number of Students Student Count and % Limited English Proficiency Eligibility for Reduced/Free Lunch Monroe-Woodbury Central 7,503 # of Students 228 677 Monroe Woodbury High School Percent 3.0 9.0 Monroe Woodbury Middle School Smith Clove Elementary School Sapphire Elementary School Pine Tree Elementary School Central Valley School Pine Bush Senior High School North Main Street School Newburgh City 11961 # of Students 1,537 7,100 Broadway School Percent 13 59 Fostertown Etc Magnet School Gams Tech Magnet School Gardnertown Fundamental Magnet School Horizon-On-The-Hudson Magnet School Heritage Junior High School Meadow Hill Global Explorations Magnet School New Windsor School Newburgh Free Academy Newburgh Prekindergarten Center North Junior High School Balmville School South Junior High School Temple Hill School West Street Pre-K Center Vails Gate High Tech Magnet School Pine Bush 6,068 # of Students 70 1388 Circleville Elementary School Percent 1.0 23 Circleville Middle School Crispell Middle School E.J. Russell Elementary School Pakanasink Elementary School Pine Bush Elementary School Pine Bush Senior High School Port Jervis City 3,118 # of Students 25 1193 Anna S. Kuhl Elementary School Percent 1.0 38 Port Jervis Middle School Port Jervis Senior High School Sullivan Avenue School N.A. Hamilton Bicentenial School Exhibit 1A. 16b 79

LIMITED ENGLISH PROFICIENCY AND ELIGIBILITY FOR FREE REDUCED LUNCH BY SCHOOL DISTRICT, 2007-2008 C. School District Total Number of Students Student Count and % Limited English Proficiency Eligibility for Reduced/Free Lunch Tuxedo Union 645 # of Students 0.0 58 George Grant Mason Elementary School Percent 0.0 9.0 George F. Baker High School Valley Central (Montgomery) 5,082 # of Students 41 1349 Walden Elementary School Percent 1.0 27 Valley Central Middle School Valley Central High School Berea Elementary School Maybrook Elementary School Montgomery Elementary School East Coldenham Elementary School Warwick Valley 4,402 # of Students 0.0 365 Park Avenue Elementary School Percent 0.0 8.0 Warwick Valley Middle School Warwick Valley High School Sanfordville Elementary School Pine Island School Kings Elementary School Washingtonville 4,773 # of Students 45 568 Washingtonville Middle School Percent 1.0 12 Washingtonville Senior High School Taft Elementary School Round Hill Elementary School Little Britain Elementary School Source: New York State Report Card for School Year 2006-2007 https://www.nystart.gov/publicweb/county.do?year=2007&county=orange Exhibit 1A. 16c 80

EDUCATIONAL ATTAINMENT OF PERSONS 25 YEARS AND OLDER BY MUNICIPALITY I Total Less Than 9th-12th High School Some College Associate Bachelor Grad/Prof'l Municipality Population 9th Grade Percent No Diploma Percent Diploma/GED Percent No Degree Percent Degree Percent of Arts Percent Degree Percent ORANGE COUNTY 212816 11942 5.6 26687 12.5 66119 31.1 42767 20.1 17348 8.2 28169 13.2 19784 9.3 Blooming Grove (T) 11117 319 2.9 991 8.9 3394 30.5 2431 21.9 1047 9.4 1761 15.8 1174 10.6 Chester (T) 8158 357 4.4 788 9.7 2405 29.5 1676 20.5 819 10.0 1363 16.7 750 9.2 Cornwall (T) 8258 174 2.1 583 7.1 2471 29.9 1439 17.4 649 7.9 1521 18.4 1421 17.2 Crawford (T) 4987 191 3.8 576 11.6 1614 32.4 1073 21.5 398 8.0 679 13.6 456 9.1 Deerpark (T) 5189 264 5.1 931 17.9 2419 46.6 790 15.2 296 5.7 300 5.8 189 3.6 Goshen (T) 8815 663 7.5 961 10.9 2279 25.9 1635 18.5 671 7.6 1568 17.8 1038 11.8 Greenville (T) 2419 70 2.9 231 9.5 928 38.4 485 20.0 230 9.5 263 10.9 212 8.8 Hamptonburgh (T) 3005 92 3.1 211 7.0 855 28.5 769 25.6 202 6.7 549 18.3 327 10.9 Highlands (T) 5664 154 2.7 392 6.9 1364 24.1 1255 22.2 490 8.7 870 15.4 1139 20.1 Middletown (C) 15805 1411 8.9 2653 16.8 4633 29.3 2979 18.8 1440 9.1 1491 9.4 1198 7.6 Minisink (T) 2295 98 4.3 221 9.6 856 37.3 467 20.3 206 9.0 281 12.2 166 7.2 Monroe (T) 14783 1036 7.0 2028 13.7 4037 27.3 2928 19.8 1034 7.0 2351 15.9 1369 9.3 Montgomery (T) 13220 579 4.4 1731 13.1 4337 32.8 2817 21.3 1198 9.1 1598 12.1 960 7.3 Mount Hope (T) 4852 531 10.9 1528 31.5 1203 24.8 638 13.1 343 7.1 360 7.4 249 5.1 Newburgh (C) 15292 2325 15.2 3477 22.7 4832 31.6 2238 14.6 700 4.6 991 6.5 729 4.8 Newburgh (T) 18749 684 3.6 1776 9.5 6182 33.0 3997 21.3 1684 9.0 2671 14.2 1755 9.4 New Windsor (T) 15069 616 4.1 1556 10.3 4844 32.1 3355 22.3 1503 10.0 1875 12.4 1320 8.8 Port Jervis (C) 5731 299 5.2 1262 22.0 2266 39.5 1050 18.3 361 6.3 260 4.5 233 4.1 Tuxedo (T) 2442 76 3.1 94 3.8 475 19.5 479 19.6 171 7.0 574 23.5 573 23.5 Wallkill (T) 16381 810 4.9 1857 11.3 5862 35.8 3420 20.9 1479 9.0 1834 11.2 1119 6.8 Warwick (T) 20577 924 4.5 1984 9.6 6107 29.7 4588 22.3 1483 7.2 3192 15.5 2299 11.2 Wawayanda (T) 4067 153 3.8 506 12.4 1355 33.3 887 21.8 413 10.2 430 10.6 323 7.9 Woodbury (T) 5941 116 2.0 350 5.9 1401 23.6 1371 23.1 531 8.9 1387 23.3 785 13.2 EDUCATIONAL ATTAINMENT OF PERSONS 25 YEARS AND OLDER BY MUNICIPALITY II Total Less Than 9th-12th High School Some College Associate Bachelor Grad/Prof'l Municipality Population 9th Grade Percent No Diploma Percent Diploma/GED Percent No Degree Percent Degree Percent of Arts Percent Degree Percent Chester (V) 2504 74 3.0 248 9.9 808 32.3 542 21.6 239 9.5 402 16.1 191 7.6 Cornwall on Hudson (V) 2080 32 1.5 121 5.8 535 25.7 366 17.6 166 8.0 424 20.4 436 21.0 Florida (V) 1685 101 6.0 131 7.8 514 30.5 370 22.0 164 9.7 257 15.3 148 8.8 Goshen (V) 3857 188 4.9 471 12.2 967 25.1 754 19.5 324 8.4 697 18.1 456 11.8 Greenwood Lake (V) 2231 53 2.4 244 10.9 804 36.0 566 25.4 171 7.7 236 10.6 157 7.0 Harriman (V) 1465 13 0.9 177 12.1 365 24.9 343 23.4 128 8.7 303 20.7 136 9.3 Highland Falls (V) 2654 133 5.0 255 9.6 878 33.1 610 23.0 214 8.1 331 12.5 233 8.8 Kiryas Joel (V) 3377 612 18.1 1261 37.3 1062 31.4 331 9.8 15 0.4 66 2.0 30 0.9 Maybrook (V) 1847 83 4.5 220 11.9 651 35.2 459 24.9 136 7.4 209 11.3 89 4.8 Monroe (V) 5009 258 5.2 312 6.2 1295 25.9 1041 20.8 490 9.8 971 19.4 642 12.8 Montgomery (V) 2245 62 2.8 209 9.3 648 28.9 440 19.6 284 12.7 332 14.8 270 12.0 Otisville (V) 655 38 5.8 83 12.7 239 36.5 144 22.0 68 10.4 43 6.6 40 6.1 Tuxedo Park (V) 518 2 0.4 17 3.3 51 9.8 76 14.7 23 4.4 144 27.8 205 39.6 Unionville (V) 369 43 11.7 51 13.8 140 37.9 73 19.8 15 4.1 29 7.9 18 4.9 Walden (V) 3746 212 5.7 609 16.3 1369 36.5 745 19.9 315 8.4 341 9.1 155 4.1 Warwick (V) 4321 242 5.6 389 9.0 1194 27.6 889 20.6 373 8.6 649 15.0 585 13.5 Washingtonville (V) 3524 136 3.9 253 7.2 1089 30.9 892 25.3 269 7.6 510 14.5 375 10.6 Source: US Census Bureau, 2000 Exhibit 1A.17 81

ORANGE COUNTY FAMILIES BY MUNICIPALITIES AND INCOME Exhibit 1A.18 82

ORANGE COUNTY STUDENTS RECEIVING REGENTS DIPLOMAS BY SCHOOL DISTRICT, 2007-2008 School District Total Graduates 2007-2008 Regents Diploma % Regents Diploma Chester Union Free School District* 64 44 69% Cornwall Central School District 275 258 94% Florida Union Free School District 61 52 85% Goshen Central School District 208 168 81% Greenwood Lake Union Free School District** N/A N/A N/A Highland Falls Central School District 123 100 81% Kiryas Joel Village Union Free School District** N/A N/A N/A Middletown City School District 385 268 70% Minisink Valley Central School District 339 275 81% Monroe-Woodbury Central School District 601 536 89% Newburgh City School District 656 425 65% Pine Bush Central School District 470 391 83% Port Jervis City School District 216 163 75% Tuxedo Union Free District 106 88 83% Valley Central School District 394 341 87% Warwick Valley Central School District 369 328 89% Washingtonville Central School District 419 352 84% *Data from 2006-2007; information is unavailable for 2007-2008 **Kiryas Joel Village and Greenwood Lake Union Free School Districts does not have high schools Source: New York State School Report Card for School Year 2007-2008 Exhibit 1A.19 83

ORANGE COUNTY PERSONS BELOW POVERTY LEVEL: 2000 bit 1A.20 84

RECIPIENTS OF FINANCIAL AND MEDICAL ASSISTANCE BY TYPE AND MUNICIPALITY, ORANGE COUNTY DECEMBER 2008 Safety Net Family Assistance Assistance (SNA)- (FA) Cash Emergency Assistance for Adults (EAA) SNA- Non Medicaid Zip Code Location Cash Food Stamps Food Stamps Mix (MA) Family Health Plus Total % of Total 10910 Arden 2 3 5 0.02% 10912 Bellvale 1 2 3 0.01% 10914 Blooming Grove 1 1 6 12 2 22 0.07% 10915 Bullville 1 1 16 13 4 35 0.11% 10916 Campbell Hall 3 2 48 157 23 233 0.75% 10917 Central Valley 1 23 1 44 12 81 0.26% 10918 Chester 8 6 1 119 3 230 47 414 1.33% 10919 Circleville 3 10 1 23 9 46 0.15% 10921 Florida 5 1 35 100 20 161 0.52% 10922 Fort Montgomery 5 10 4 19 0.06% 10924 Goshen 4 9 1 167 2 643 52 878 2.83% 10925 Greenwood Lake 7 9 69 1 147 37 270 0.87% 10926 Harriman 1 2 36 1 74 20 134 0.43% 10928 Highland Falls 11 4 4 76 4 123 32 254 0.82% 10930 Highland Mills 5 2 1 65 141 26 240 0.77% 10932 Howells 1 6 3 1 11 0.04% 10933 Johnson 1 6 1 9 2 19 0.06% 10940 Middletown 290 170 67 1774 83 3029 608 6021 19.38% 10941 Scotchtown 20 20 3 192 2 327 89 653 2.10% 10943 Middletown 1 1 0.00% 10949 Monroe 9 9 0.03% 10950 Monroe 39 18 25 1716 37 2696 673 5204 16.75% 10953 Mountainville 2 2 0.01% 10958 New Hampton 6 12 4 33 1 68 12 136 0.44% 10959 New Milford 1 1 0.00% 10963 Otisville 4 5 1 52 74 16 152 0.49% 10969 Pine Island 1 12 28 2 43 0.14% 10973 Slate Hill 2 46 48 4 100 0.32% 10975 Southfield 1 6 4 11 0.04% 10979 Sterling Forest 1 5 2 8 0.03% 10981 Sugarloaf 2 3 1 6 0.02% 10985 Thompson Ridge 1 3 11 1 16 0.05% 10986 No Matching Zip 1 1 0.00% 10987 Tuxedo 1 2 17 37 3 60 0.19% 10988 Unionville 2 14 24 8 48 0.15% 10990 Warwick 12 8 2 181 1 425 69 698 2.25% 10992 Washingtonville 5 4 2 126 2 220 33 392 1.26% 10996 West Point 2 5 7 0.02% 10997 West Point 1 1 0.00% 10998 Westtown 41 69 14 124 0.40% 12518 Cornwall 3 1 2 67 3 97 21 194 0.62% 12520 Cornwall on Hudson 2 1 2 24 52 7 88 0.28% 12543 Maybrook 9 6 3 103 5 126 25 277 0.89% 12549 Montgomery 15 6 3 155 5 295 49 528 1.70% Source: Orange County Department of Social Services Exhibit 1A.21a 85

RECIPIENTS OF FINANCIAL AND MEDICAL ASSISTANCE BY TYPE AND MUNICIPALITY, ORANGE COUNTY DECEMBER 2008 Family Safety Net Emergency Assistance Assistance Assistance SNA- Non for Adults Food Stamps Medicaid Family Health % of Zip Code Location (FA) (SNA)-Cash Cash (EAA) Food Stamps Mix (MA) Plus Total Total 12550 Newburgh 523 225 226 1 2183 171 3554 649 7532 24.25% 12551 Newburgh 4 6 1 11 0.04% 12552 Newburgh 2 2 0.01% 12553 New Windsor 57 26 10 347 13 713 150 1316 4.24% 12566 Pine Bush 7 3 1 113 1 138 37 300 0.97% 12575 Rock Tavern 4 1 24 3 47 6 85 0.27% 12577 Salisbury Mills 2 2 1 21 1 28 5 60 0.19% 12584 Vails Gate 3 12 1 16 0.05% 12586 Walden 32 16 6 233 7 442 106 842 2.71% 12721 Bloomingburgh 3 1 1 19 1 57 9 91 0.29% 12729 Cuddebackville 10 3 1 50 3 88 22 177 0.57% 12737 Mt. Hope 1 1 0.00% 12739 Godeffroy 4 4 2 10 0.03% 12746 Huguenot 3 1 1 20 49 8 82 0.26% 12771 Port Jervis 106 33 16 624 34 775 204 1792 5.77% 12780 Sparrowbush 8 1 1 48 2 80 18 158 0.51% 12785 Westbrookville 5 12 3 20 0.06% Total of In-County Cases 1215 605 386 1 8950 389 15401 3154 30101 Total of Out-of-County Cases 10 7 71 0 75 2 765 28 958 Grand Totals 1225 612 457 1 9025 391 16166 3182 31062 Source: Orange County Department of Social Services Exhibit 1A.21b 86

Orange County Department of Social Services Population Served, 2006-2008 HUMAN SERVICES 2006 2007 2008 Investigations of reported Child Abuse/Neglect (Children under age 18) 3,167 3,473 3,452 Children in care (mo. average) 460 465 468 Total children freed for adoption 54 52 23 Children adopted 30 40 54 PINS (Persons in Need of Supervision) placed 42 17 16 Including PINS over age 16 29 20 10 ECONOMIC INDEPENDENCE 2006 2007 2008 Temporary Assistance (TA) applications filed 6,216 5,806 7,298 TA cases (end of year) 1,935 2,005 2,518 TA recipients (end of year) 4,336 4,611 5,389 -Family Assistance (FA) cases (end of year) 1,065 1,149 1,314 -Safety Net Assistance (SNA) cases (end of year) 870 856 1,204 Home Energy Assistance Program (HEAP) applications 1,826 1,587 25,042* Medicaid applications filed 12,511 11,589 12,529 Medicaid only (MA) cases (end of year) 17,243 17,592 19,367 Family Health Plus (FHP) Cases (end of year) *incl. in MA only cases above 2,565 2,914 2,890 Medical Transportation requests (ambulance, ambulette & taxi) 140,897 137,465 163,480 FS only cases (end of year) 8,022 8.410 9,733 Employment of TA recipients (via Employment & Training Adm.) 1,094 1,177 1,204 Homeless applicants/cases 2,198 2,535 3,511 Cases diverted to other housing remedies or ineligible 1,580 1,619 1,778 Homeless cases/households- Temporarily housed at Emergency Housing Shelter (mo. average) 32 33 39 Temporarily housed at Hotel/Motel (mo. average) 21 42 101 Temporarily housed in transitional housing- Project Life (mo. average) 14 17 16 ADMINISTRATIVE DIVISION 2006 2007 2008 Child Support cases (end of year) 30,981 34,058 37,290 Child Support collected (end of year) $3.3mil $2.7mil $3.3mil DSS Cases with substantiated fraud (Special Investigation results) 266 274 338 Child Care Subsidy Cases (mo. average) 674 636 686 KEY: *2008 HEAP data represents the total number of payments during the season not applications Source: Orange County Department of Social Services, 2009 Exhibit 1A.22 87

DEMOGRAPHIC PROFILE OF PUBLIC SCHOOL DISTRICTS IN ORANGE COUNTY, 2007-2008 Asian or Native Hawaiian/ Pacific Islander (% Enrolled) Racial/Ethnic Origin (2007-2008) Black- Non-Hispanic (% Enrolled) Hispanic (% Enrolled) White Non-Hispanic (% Enrolled) Attendance and Drop-Out Rate Student Annual Attendance Rates (2007-2008) Suspensions from 2007-2008 (Rate) Drop-Outs from 2007-2008 (Rate) School District Chester Union 36 (4%) 109 (11%) 166 (17%) 681 (69%) 95% 20 (2%) 7 (2%) Cornwall Central 141 (4%) 189 (6%) 325 (10%) 2,662 (80%) 95% 119 (4%) 17 (1%) Florida Union 19 (2%) 52 (6%) 121 (14%) 657 (77%) 96% 29 (3%) 1 (0%) Goshen Central 80 (3%) 139 (5%) 310 (11%) 2,365 (82%) 95% 63 (2%) 8 (1%) Greenwood Lake Union 11 (2%) 23 (4%) 72 (12%) 487 (82%) 94% 10 (2%) 0 (0%) Highlands Falls Central 24 (8%) 109 (9%) 190 (16%) 732 (62%) 93% 64 (5%) 13 (2%) Kiryas Joel Village* 0 (0%) 0 (0%) 12 (6%) 205 (94%) 90% 0 (0%) 1 (4%) Middletown City 160 (2%) 1778 (27%) 2,862 (43%) 1,780 (27%) 93% 704 (10%) 150 (5%) Minisink Valley Central 56 (1%) 246 (5%) 516 (11%) 3,811 (82%) 94% 255 (5%) 35 (2%) Monroe-Woodbury Central 428 (6%) 447 (6%) 1,085 (14%) 5,514 (73%) 96% 173 (2%) 30 (1%) Newburgh City 268 (2%) 3563 (30%) 4,611 (39%) 3,500 (29%) 93% 1167 (10%) 267 (6%) Pine Bush 112 (2%) 700 (12%) 704 (12%) 4,496 (74%) 94% 471 (8%) 66 (3%) Port Jervis City 24 (1%) 235 (8%) 228 (7%) 2,610 (84%) 92% 294 (9%) 63 (5%) Tuxedo Union 15 (2%) 13 (2%) 80 (12%) 526 (82%) 97% 44 (7%) 2 (0%) Valley Central (Montgomery) 75 (1%) 473 (9%) 706 (14%) 3,810 (75%) 95% 644 (13%) 48 (2%) Warwick Valley 70 (2%) 223 (5%) 317 (7%) 3,745 (85%) 96% 160 (4%) 5 (0%) Washingtonville 128 (3%) 275 (6%) 650 (14%) 3,701 (78%) 96% 361 (8%) 33 (2%) Source: New York State Education Department, School Report Card for School Year 2007-2008 https://www.nystart.gov/publicweb/county.do?year=2007&county=orange Exhibit 1A. 23 88

POVERTY STATUS BY AGE, RACE, ETHNICITY AND HOUSEHOLD TYPE IN ORANGE COUNTY, 2000 A. POPULATION BELOW POVERTY LEVEL BY AGE GROUP AND RACE* IN THE 2000 CENSUS, ORANGE COUNTY Black or African American Indian and Alaskan One Race Native Hawaiian & other Pacific Two or more Age Group Total White American Native Asian Islander Race races 14,710 9,784 2,325 146 161 2 1,284 1,008 Population under age 18 below poverty Under age 5 4,780 3,373 735 20 11 2 263 376 Age 5 857 502 160 11 13 0 66 105 Ages 6 to 11 5,108 3,221 829 63 118 0 553 324 Ages 12 to 17 3,965 2,688 601 52 19 0 402 203 17,291 12,201 2,615 131 270 0 1,444 630 Population ages 18 to 64 below poverty 2,671 2,281 294 3 11 0 56 26 Population age 65 and over below poverty *Hispanics, who can be of any race, are included in the racial figures shown here. Some other B. POPULATION BELOW POVERTY BY AGE GROUP AND HISPANIC ORIGIN STATUS IN THE 2000 CENSUS, ORANGE COUNTY Non-Hispanic Other Age Group Total Hispanic White Races 14,710 3,324 8,502 2,884 Population under age 18 below poverty Under age 5 4,780 1,025 2,952 803 Age 5 857 182 439 236 Ages 6 to 11 5,108 1,272 2,768 1,068 Ages 12 to 17 3,965 845 2,343 777 17,291 3,704 10,373 3,214 Population ages 18 to 64 below poverty Population age 65 and over below poverty 2,671 176 2,161 334 Exhibit 1A. 24 89

EMPLOYED PERSONS 16 YEARS AND OVER BY MUNICIPALITY AND OCCUPATION: ORANGE COUNTY, 2000 Management & Professional Services. Farming, Fishing, and Forestry Construction, Extraction, and Maintenance Production, Transportation, and Material Moving % Employed per Municipality Sales & Municipalities Service Office Orange County 50,357 25,050 41,809 602 15,533 18,393 60 Blooming Grove (T) 2,933 1,405 2,429 0 945 801 67 Chester (T) 2,113 879 1,775 11 548 492 63 Cornwall (T) 2,594 813 1,508 10 604 443 64 Crawford (T) 1,361 582 1,000 25 465 364 66 Deer park (T) 693 728 856 8 599 699 59 Goshen (T) 2,362 772 1,352 73 400 505 54 Greenville (T) 634 325 450 5 249 229 68 Hampton burgh (T) 792 371 664 0 293 171 66 Highlands (T) 1,467 706 906 14 284 320 37 Middletown (C) 2,890 2,303 3,093 121 895 1,550 57 Minis ink (T) 561 342 378 22 204 205 65 Monroe (T) 4,032 1,528 3,333 11 901 1,110 55 Montgomery (T) 3,018 1,611 2,690 43 1,214 1,375 65 Mount Hope (T) 713 381 632 15 326 258 43 Newburgh (C) 1,903 2,393 2,511 35 839 2,866 54 Newburgh (T) 4,956 1,917 3,691 45 1,515 1,607 65 New Windsor (T) 3,538 1,776 3,249 8 1,174 1,092 62 Port Jervis (C) 693 791 993 27 462 827 57 Tuxedo (T) 810 234 527 2 151 94 68 Wallkill (T) 3,473 1,928 3,950 30 1,258 1,503 64 Warwick (T) 5,817 2,092 3,775 62 1,510 1,231 62 Wawayanda (T) 933 570 755 18 301 374 63 Woodbury (T) 2,071 603 1,292 17 396 277 69 Source: US Census Bureau, 2000 Exhibit 1A.25 91

SELECTED HOUSING CHARACTERISITCS IN ORANGE COUNTY BY MUNICIPALITY, 2000 Owner Occupied 1.00 or more Percentage occupants of > 1 per per room room Renter Occupied 1 or more Percentage occupants per of > 1 per room room Orange County Municipalities Total Total Orange County 114788 1145 1.0 37840 3692 9.8 Blooming Grove 5836 58 1.2 1093 54 5.2 Chester 3848 17 0.6 796 5 0.6 Cornwall 4630 18 0.6 1340 40 3.1 Crawford 2707 33 1.6 630 0 0.0 Deerpark 2906 10 0.4 540 22 4.2 Goshen 4074 28 1.0 1276 58 4.8 Greenville 1243 12 1.1 155 6 4.0 Hamptonburgh 1466 13 1.0 156 5 3.3 Highlands 3226 35 2.8 1924 57 3.1 Middletown city 9478 96 2.3 5150 660 14.7 Minisink 1182 3 0.3 212 8 3.9 Monroe 8249 303 5.9 2770 642 30.2 Montgomery 7273 55 1.1 2061 87 4.4 Mount Hope 1582 15 1.2 276 8 3.0 Newburgh city 9147 135 5.1 6345 1273 25.1 Newburgh town 9761 49 0.6 1719 117 7.3 New Windsor 8398 63 1.1 2492 106 4.4 Port Jervis city 3521 2 0.1 1920 135 7.6 Tuxedo 1337 0 0.0 349 12 3.6 Wallkill 8866 101 1.9 3440 280 8.9 Warwick 10868 76 0.9 2369 70 3.0 Wawayanda 2095 23 1.3 304 20 7.0 Woodbury 3095 0 0.0 523 27 5.4 Source: US Census 2000 Summary File Exhibit 1A. 26a 92

HOUSING UNITS PRE-1950 CONSTRUCTION, ORANGE COUNTY, 2000 Municipality Total Total Pre-1950 Percent Pre-1950 Orange County 122,754 52,059 42.4 Blooming Grove 6,559 2,000 30.5 Chester 3,984 847 21.3 Cornwall 4,857 2,632 54.2 Crawford 2,851 895 31.4 Deer park 3,332 1,183 35.5 Goshen 4,320 1,643 38.0 Greenville 1,365 312 22.9 Hampton burgh 1,578 485 30.7 Highlands 3,414 2,051 60.1 Middletown city 10,141 6,076 59.9 Minisink 1,245 539 43.3 Monroe 8,537 2,178 25.5 Montgomery 7,643 3,398 44.5 Mount Hope 1,714 742 43.3 Newburgh city 10,479 7,620 72.7 Newburgh town 10,118 3,899 38.5 New Windsor 8,714 2,762 31.7 Port Jervis city 3,830 3,046 79.5 Tuxedo 1,457 673 46.2 Wallkill town 9,287 2,158 23.2 Warwick town 11,818 5,124 43.4 Wawayanda 2,174 770 35.4 Woodbury 3,337 1,026 30.7 Source: US Census, 2000 Exhibit 1A. 26b 93

HOUSEHOLDS WITH RENTER-OCCUPIED HOUSING UNITS WITH COST OF 30 PERCENT OR MORE OF GROSS INCOME, 1999 Municipalities Total Greater than 30% Percent > 30% Orange County 37,388 14,873 39.8 Blooming Grove 1,072 427 39.8 Chester 787 210 26.7 Cornwall 1,325 535 40.4 Crawford 587 151 25.7 Deerpark 535 230 43.0 Goshen 1,254 628 50.1 Greenville 152 47 30.9 Hamptonburgh 126 51 40.5 Highlands 1,917 285 14.9 Middletown city 5,137 2399 46.7 Minisink 186 69 37.1 Monroe 2,770 1437 51.9 Montgomery 2,040 683 33.5 Mount Hope 263 99 37.6 Newburgh city 6,334 2911 46.0 Newburgh town 1,696 454 26.8 New Windsor 2,472 781 31.6 Port Jervis city 1,920 910 47.4 Tuxedo 345 93 27.0 Wallkill 3,404 1262 37.1 Warwick 2,267 926 40.8 Wawayanda 286 112 39.2 Woodbury 513 173 33.7 Source: US Bureau of the Census Exhibit 1A. 26c 94

HOUSEHOLDS WITH OWNER COSTS OF 30 OR MORE OF GROSS INCOME AMONG OWNER OCCUPIED HOUSING UNITS IN ORANGE COUNTY, 1999 Housing Units with a Mortgage, 1999 A Municipality Total Housing Units 30% and More Percent >=30% Not Computed Percent >=30% Blooming Grove 3,445 1006 29.2 12 0.3 Chester 2,210 616 27.9 0 0.0 Cornwall 2,096 638 30.4 11 0.5 Crawford 1,222 353 28.9 5 0.4 Deerpark 1,061 322 30.3 0 0.0 Goshen 1,747 431 24.7 7 0.4 Greenville 682 231 33.9 3 0.4 Hamptonburgh 958 273 28.5 6 0.6 Highlands 579 196 33.9 0 0.0 Middletown city 2,522 702 27.8 7 0.3 Minisink 622 205 33.0 5 0.8 Monroe 3,414 1072 31.4 11 0.3 Montgomery 3,312 1043 31.5 5 0.2 Mount Hope 829 252 30.4 0 0.0 Newburgh city 1,376 513 37.3 0 0.0 Newburgh town 5,248 1373 26.2 16 0.3 New Windsor 3,420 947 27.7 6 0.2 Port Jervis city 752 228 30.3 0 0.0 Tuxedo 606 172 28.4 0 0.0 Wallkill 3,642 1072 29.4 24 0.7 Warwick 5,949 1901 32.0 8 0.1 Wawayanda 1,102 350 31.8 0 0.0 Woodbury 1,964 571 29.1 0 0.0 Housing Units without a Mortgage, 1999 B Municipality Total Housing Units 30% and More Percent >=30% Not Computed Percent >=30% Blooming Grove 799 110 13.8 21 2.6 Chester 459 84 18.3 0 0.0 Cornwall 818 114 13.9 4 0.5 Crawford 421 96 22.8 0 0.0 Deerpark 533 38 7.1 10 1.9 Goshen 710 129 18.2 0 0.0 Greenville 174 30 17.2 2 1.1 Hamptonburgh 219 20 9.1 0 0.0 Highlands 414 70 16.9 0 0.0 Middletown city 1,134 167 14.7 14 1.2 Minisink 165 30 18.2 0 0.0 Monroe 896 159 17.7 8 0.9 Montgomery 1,143 166 14.5 28 2.4 Mount Hope 278 46 16.5 2 0.7 Newburgh city 603 55 9.1 7 1.2 Newburgh town 1,884 186 9.9 26 1.4 New Windsor 1,307 199 15.2 12 0.9 Port Jervis city 636 137 21.5 0 0.0 Tuxedo 234 32 13.7 0 0.0 Wallkill 1,074 132 12.3 6 0.6 Warwick 1,764 437 24.8 22 1.2 Wawayanda 368 47 12.8 0 0.0 Woodbury 368 44 12.0 0 0.0 Source: US Census Bureau, 2000 Exhibit 1A. 26d 95

PROJECTED POPULATION OF ORANGE COUNTY 2005-2025 % Annual Avg growth 2005 2010 2015 2020 2025 Orange County 1.24 363,099 386,215 410,802 436,954 464,772 Blooming Grove (T) 2.58 19,704 22,376 25,410 28,855 32,768 Chester(T) 1.86 13,310 14,593 15,999 17,541 19,231 Cornwall(T) 1.26 13,100 13,943 14,841 15,797 16,814 Crawford(T) 1.63 8,538 9,257 10,036 10,881 11,797 Deerpark(T) 0.77 8,164 8,483 8,814 9,157 9,515 Goshen(T) 1.03 13,590 14,302 15,052 15,842 16,672 Greenville(T) 1.79 4,153 4,539 4,960 5,421 5,924 Hamptonburgh(T) 1.53 5,056 5,456 5,887 6,353 6,855 Highlands(T) 1.38 13,370 14,318 15,334 16,422 17,587 Middletown(T) 0.79 26,405 27,463 28,564 29,709 30,899 Minisink(T) 1.02 3,771 3,966 4,172 4,388 4,615 Monroe(T) 1 3.26 36,877 43,300 50,842 59,697 70,095 Montgomery(T) 1.39 22,380 23,976 25,685 27,516 29,477 Mount Hope(T) 1.74 7,239 7,892 8,605 9,382 10,230 Newburgh(C) 2 0.17 28,498 28,738 28,981 29,225 29,472 Newburgh(T) 2.27 30,835 34,489 38,576 43,148 48,261 New Windsor(T) 2.79 26,235 30,099 34,534 39,621 45,458 Port Jervis (C) -0.05 8,839 8,818 8,797 8,776 8,756 Port Jervis(C) 2 0.35 9,061 9,175 9,337 9,501 9,669 Tuxedo(T) 0.69 3,451 3,572 3,697 3,826 3,960 Wallkill(T) 2.48 27,870 31,499 35,601 40,237 45,476 Warwick(T) 1.68 33,437 36,343 39,502 42,934 46,666 Wawayanda(T) 1.42 6,733 7,226 7,756 8,324 8,935 Woodbury(T) 2 10,443 11,529 12,727 14,049 15,509 Chester(V) 2.21 3,842 4,285 4,779 5,330 5,945 Cornwall on Hudson (V) 0.8 3,182 3,311 3,445 3,584 3,730 Florida(V) 1.36 2,751 2,944 3,150 3,371 3,607 Goshen(V) 1.08 5,990 6,321 6,671 7,040 7,429 Greenwood Lake(V) 1 4.14 4,177 5,116 6,265 7,673 9,397 Harriman(V) 1 3.41 2,663 3,149 3,724 4,404 5,207 Highland Falls(V) 2 0.02 3,681 3,685 3,688 3,692 3,695 Kiryas Joel(V) * n/a n/a n/a n/a n/a n/a Maybrook(T) (V) 1.79 3,371 3,684 4,026 4,400 4,809 Monroe(V) 1 3.24 9,126 10,705 12,557 14,730 17,278 Montgomery(V) 2.81 4,176 4,797 5,510 6,328 7,269 Otisville(V) 2 0.2 999 1,009 1,019 1,029 1,039 Tuxedo Park(V) 2 0.17 737 744 750 757 763 Unionville(V) 0.59 552 569 586 603 621 Walden(V) 0.64 6,362 6,567 6,779 6,997 7,222 Warwick(V) 1.72 6,984 7,607 8,285 9,024 9,829 Washingtonville(V) 1 4.29 7,220 8,908 10,992 13,563 16,735 Town population include villages * No available data 1 Highest Growth Rate Lowest Growth Rate Source: Orange County Department of Planning Exhibit 1A.27 96

Sex Orange County Preliminary Population Projections By Age and Gender, 2005-2035 Age group Census9 0 Census0 0 2005 2010 2015 2020 2025 2030 2035 Total 307,647 341,367 372,751 394,152 416,408 439,204 461,570 482,828 503,040 Male 0 to 4 13,166 13,439 12,999 13,603 14,523 15,387 15,962 16,417 17,016 Male 5 to 9 12,533 14,886 14,822 14,165 14,881 15,832 16,661 17,260 17,779 Male 10 to 14 11,619 14,796 15,567 15,064 14,684 15,435 16,371 17,179 17,783 Male 15 to 19 12,530 13,810 15,719 16,171 15,686 15,588 16,361 17,307 18,096 Male 20 to 24 12,752 11,080 13,580 15,175 15,645 15,178 15,427 16,207 17,099 Male 25 to 29 12,604 9,505 10,113 11,842 13,064 13,449 13,033 13,433 14,122 Male 30 to 34 14,361 12,054 11,928 12,155 13,887 15,031 15,389 14,931 15,564 Male 35 to 39 13,211 14,887 14,666 13,843 14,213 15,988 17,101 17,490 16,987 Male 40 to 44 11,962 14,979 15,845 15,144 14,435 14,845 16,567 17,646 18,043 Male 45 to 49 9,275 12,580 15,094 15,685 15,000 14,358 14,767 16,421 17,455 Male 50 to 54 6,891 11,145 12,610 14,805 15,385 14,697 14,097 14,511 16,101 Male 55 to 59 6,043 8,043 10,602 11,900 13,943 14,478 13,812 13,274 13,675 Male 60 to 64 5,201 5,674 7,270 9,458 10,650 12,444 12,903 12,305 11,850 Male 65 to 69 4,444 4,529 5,101 6,375 8,307 9,370 10,911 11,308 10,781 Male 70 to 74 3,390 3,691 4,145 4,517 5,637 7,345 8,291 9,628 9,974 Male 75 to 79 2,452 2,899 2,995 3,247 3,546 4,424 5,764 6,518 7,559 Male 80 to 84 1,426 1,661 2,050 2,088 2,256 2,470 3,083 4,026 4,567 Male 85 and up 851 1,307 1,424 1,689 1,856 2,026 2,228 2,652 3,370 Female 0 to 4 12,461 12,531 12,406 12,982 13,861 14,685 15,235 15,669 16,240 Female 5 to 9 11,893 13,860 14,270 13,919 14,615 15,556 16,399 17,006 17,525 Female 10 to 14 10,799 13,803 14,847 14,793 14,679 15,429 16,399 17,245 17,873 Female 15 to 19 10,169 11,744 13,759 14,439 14,365 14,427 15,183 16,122 16,918 Female 20 to 24 10,156 8,858 10,560 12,075 12,657 12,559 12,817 13,523 14,338 Female 25 to 29 12,391 9,423 9,727 11,106 12,404 12,914 12,760 13,231 13,956 Female 30 to 34 13,922 12,437 12,323 12,300 13,802 15,086 15,609 15,372 16,111 Female 35 to 39 12,829 14,829 14,889 14,068 14,187 15,763 17,051 17,602 17,302 Female 40 to 44 11,618 14,404 15,478 15,027 14,298 14,469 16,024 17,274 17,815 Female 45 to 49 8,964 12,597 14,829 15,598 15,109 14,437 14,641 16,171 17,382 Female 50 to 54 6,590 10,899 12,698 14,614 15,352 14,840 14,216 14,440 15,925 Female 55 to 59 5,877 8,057 10,609 12,281 14,114 14,798 14,269 13,707 13,943 Female 60 to 64 5,746 5,862 7,526 9,771 11,312 12,985 13,598 13,094 12,602 Female 65 to 69 5,506 5,057 5,608 7,010 9,105 10,529 12,061 12,609 12,112 Female 70 to 74 4,848 4,979 4,840 5,180 6,456 8,377 9,676 11,062 11,545 Female 75 to 79 3,928 4,415 4,626 4,368 4,683 5,821 7,545 8,706 9,934 Female 80 to 84 2,846 3,319 3,614 3,719 3,535 3,802 4,724 6,137 7,081 Female 85 and up 2,393 3,328 3,612 3,976 4,276 4,382 4,635 5,345 6,617 Source:Formerly CISER; Now PAD; printed November 2008 bit 1A. 28 97

ORANGE COUNTY REGIONAL COMPARISONS, 2000 Source: Orange County Department of Planning Exhibit 1A. 29 98

ORANGE COUNTY REGIONAL COMPARISONS-INCOME AND EDUCATIONAL ATTAINMENT, 2000 Exhibit 1A. 30 99

Created by the School of Public Health, University at Albany, January, 2005 Exhibit 1A. 31 100

ORANGE COUNTY MUNICIPALITIES BY ZIP CODE, 2009 Zip Codes Towns Zip Codes Towns 10910 ARDEN 10985 THOMPSON RIDGE 10911 BEAR MOUNTAIN 10987 TUXEDO 10912 BELLVALE 10988 UNIONVILLE 10914 BLOOMING GROVE 10990 WARWICK 10915 BULLVILLE 10992 WASHINGTONVILLE 10916 CAMPBELL HALL 10996 WEST PT 10917 CENTRAL VALLEY 10998 WESTTOWN 10918 CHESTER 12518 CORNWALL 10919 CIRCLEVILLE 12520 CORNWALLONHUDSO 10921 FLORIDA 12540 MARLBORO 10922 FT MONTGOMERY 12543 MAYBROOK 10924 GOSHEN 12549 MONTGOMERY 10925 GREENWOOD LAKE 12550 NEWBURGH 10926 HARRIMAN 12553 NEW WINDSOR 10928 HIGHLAND FALLS 12566 PINE BUSH 10930 HIGHLAND MILLS 12575 ROCK TAVERN 10932 HOWELLS 12577 SALISBURY MILLS 10933 JOHNSON 12584 VAILS GATE 10940 MIDDLETOWN 12586 WALDEN 10941 MIDDLETOWN 12589 WALLKILL 10950 MONROE 12721 BLOOMINGBURG 10953 MOUNTAINVILLE 12729 CUDDEBACKVILLE 10958 NEW HAMPTON 12737 MT. HOPE 10963 OTISVILLE 12739 GODEFFROY 10969 PINE ISLAND 12746 HUGUENOT 10973 SLATEHILL 12771 PORT JERVIS 10975 SOUTHFIELD 12780 SPARROWBUSH 10979 STERLING FOREST 12785 WESTBROOKVILLE 10981 SUGAR LOAF Exhibit 1A. 32 101

MORTALITY FROM ALL CAUSES BY BY GENDER, RACE, ETHNICITY, AGE GROUPS AND HEALTH PLANNING ZONES, ORANGE COUNTY, UPSTATE NY, 2004-2006 2004 2005 2006 Number of Number of Number of Deaths Rate Deaths Rate Deaths Rate Total Orange County 2,429 759.8 2,388 737.9 2,333 709.5 Upstate NY 95,389 761.0 95,212 754.6 93,423 735.6 Orange County 1,157 892.3 1,131 868.5 1,111 834.5 Males+ Upstate NY 44,825 864.3 44,793 856.1 44,452 841.6 Females+ Orange County 1,272 652.1 1,257 638.6 1,222 615.3 Upstate NY 50,564 675.8 50,419 671.0 48,971 649.3 Race/ Ethnicity White 2,196 739.6 2,125 712.4 2,113 697.8 Black 157 791.7 169 796.0 161 734.5 Other 72 503.9 87 481.4 53 437.1 Hispanic 127 564.3 131 576.0 96 376.3 Age* < 5 s/n s/n 25 97.6 s/n s/n 5-14 s/n s/n s/n s/n s/n s/n 15-24 33 60.1 42 74.4 28 48.5 25-34 43 92.2 39 82.4 38 78.3 35-44 84 144.8 71 124.0 66 118.6 45-54 174 325.6 150 274.7 169 303.7 55-64 251 731.4 254 709.8 268 720.9 65-74 404 2,149.5 399 2,102.8 394 2,042.2 75-84 648 5,165.4 655 5,229.5 624 5,007.6 85+ 754 15,137.5 741 14,638.5 724 13,990.3 Zones Central 615 766.2 597 772.0 592 732.6 East 653 694.7 658 695.3 615 653.1 Middletown City 263 955.8 240 921.5 208 787.9 Newburgh City 217 953.6 199 879.6 198 908.5 North 244 759.3 226 700.5 228 697.1 Port Jervis City 106 987.6 102 919.3 98 902.2 West 331 704.6 366 687.5 393 722.4 Rates per 100,000 population Except as noted all mortality rates are age-sex adjusted to the 2000 U.S. Standard population (Healthy People 2010 Statistical Notes, Number 20, January 2001). +Age adjusted mortality rate *Crude mortality rate (i.e., not age or sex adjusted) Populations used in calculating rates are from the Vintage 1990 population with bridged race estimates, Census 2000, and Vintage 2000 with bridged race estimates. Vintage data was downloaded from the National Center for Health Statistics. Population data for gender, racial and ethnic groups for Health Planning Zones was derived from the Census 2000 for these racial groups and interpolated from the Vintage estimates by town. s/n = data are unreliable due to small numbers Mortality rates are based on events with known age and gender Data Source: NYS DOH Vital Statistics. Deaths for Orange County residents that were recorded in NYC are not recorded in this analysis. Data analysis and table by the School of Public Health, University at Albany, August, 2009. Exhibit 1A.33a 102

MORTALITY FROM ALL CAUSES BY BY GENDER, RACE, ETHNICITY, AGE GROUPS AND HEALTH PLANNING ZONES, ORANGE COUNTY, UPSTATE NY, 1998-2006 1998-2000 2001-2003 2004-2006 Number of Number of Number of Deaths Rate Deaths Rate Deaths Rate Total Orange County 7,186 814.9 7,315 783.6 7,150 734.6 Upstate NY 291,083 816.1 293,203 694.0 284,023 750.5 Males+ Orange County 3,374 964.4 3,380 907.6 3,399 864.8 Upstate NY 137,637 945.3 137,876 676.8 134,069 853.8 Females+ Orange County 3,812 703.7 3,935 688.9 3,751 635.2 Upstate NY 153,446 713.5 155,327 702.4 149,954 665.4 Race/ Ethnicity White 6,701 762.1 6,720 722.7 6,434 716.8 Black 450 941.6 501 899.6 487 773.5 Other 31 s/n 88 218.4 212 157.1 Hispanic 225 1,085.2 306 567.5 354 499.7 Age* < 5 58 74.3 56 73.0 57 73.9 5-14 35 20.7 36 20.0 39 22.5 15-24 83 62.1 110 72.0 103 60.9 25-34 118 88.8 96 72.0 120 84.2 35-44 234 133.6 263 149.0 221 129.5 45-54 471 345.1 510 334.0 493 301.2 55-64 761 950.9 789 856.0 773 720.5 65-74 1,327 2,415.9 1,219 2,202.0 1,197 2,097.7 75-84 2,040 5,601.9 2,060 5,498.9 1,927 5,134.4 85+ 2,054 15,261.2 2,172 15,020.0 2,219 14,581.4 Zones Central 1,913 922.1 1,849 735.7 1,804 746.5 East 1,802 690.2 1,985 675.8 1,926 680.8 Middletown City 767 876.7 726 928.3 711 887.8 Newburgh City 623 940.3 633 953.2 614 914.7 North 718 810.8 719 774.8 698 716.2 Port Jervis City 332 1,085.6 309 991.7 306 936.1 West 1,031 711.4 1,094 703.0 1,090 679.3 Rate per 100,000 population Except as noted all mortality rates are age-sex adjusted to the 2000 U.S. Standard population (Healthy People 2010 Statistical Notes, Number 20, January 2001). +Age adjusted mortality rate *Crude mortality rate (i.e., not age or sex adjusted) s/n p= Data are unreliable due to g small number of cases g p p g,, g g Vintage data was downloaded from the National Center for Health Statistics. Population data for gender, racial and ethnic groups for Health Planning Zones was derived from the Census 2000 for these racial groups and interpolated from the Vintage estimates by town. Mortality rates are based on events with known age and gender Data Source: NYS DOH Vital Statistics. Deaths for Orange County residents that were recorded in NYC are not recorded in this analysis. Data analysis and table by the School of Public Health, University at Albany, August, 2009. Exhibit 1A.33b 103

MORTALITY FROM ALL CAUSES BY GENDER, PER 100,000, ORANGE COUNTY AND UPSTATE NEW YORK, 1998-2006 1,200.0 1,000.0 800.0 Mortality Rate 600.0 400.0 200.0 - Orange County Upstate NY Orange County Upstate NY Males+ Females+ 1998 2000 2001 2003 2004 2006 Data recorded in NYC are not included in this analysis. Graph prepared by SUNY Albany School of Public Health, August, 2009 +Age adjusted mortality rate Data Source: NYS DOH Vital Statistics Exhibit 1A.33c 104

TOP TEN CAUSES OF DEATH, ORANGE COUNTY, UPSTATE NEW YORK AND NEW YORK STATE, 2005-2007 Disease Diseases of the Heart Malignant Neoplasms CLRD Cerebrovascular Disease Total Accidents Pneumonia Diabetes Mellitus Cirrhosis of the Liver AIDS Homicide and Legal Intervention Total Deaths ORANGE COUNTY Rank Number of Deaths 1 2,065 28.1 2 1,824 24.9 3 443 6.0 4 343 4.7 5 294 4.0 6 232 3.2 7 181 2.5 8 83 1.1 9 31 0.4 10 23 0.3 7,337 Percent of Total Deaths (all causes) n= 7,337 Disease Rank Diseases of the Heart Malignant Neoplasms CLRD Cerebrovascular Disease Pneumonia Total Accidents Diabetes Mellitus AIDS Cirrhosis of the Liver Homicide and Legal Intervention Total Deaths NEW YORK STATE Number of Deaths Percent of Total Deaths (all causes) n= 444,868 1 151,517 34.1 2 105,511 23.7 3 19,533 4.4 4 18,757 4.2 5 14,941 3.4 6 13,681 3.1 7 11,583 2.6 8 4,429 1.0 9 3,703 0.8 10 2,695 0.6 444,868 REST OF STATE Disease Diseases of the Heart Malignant Neoplasms CLRD Cerebrovascular Disease Total Accidents Pneumonia Diabetes Mellitus Cirrhosis of the Liver Homicide and Legal Intervention AIDS Total Deaths Rank Number of Deaths Percent of Total Deaths (all causes) n= 282,032 1 86,166 30.6 2 68,301 24.2 3 15,098 5.4 4 13,784 4.9 5 9,569 3.4 6 7,178 2.5 7 6,563 2.3 8 2,409 0.9 9 1,024 0.4 10 802 0.3 282,032 Source: NYSDOH Vital Statistics Report as of June, 2009 Exhibit 1.34 http://www.health.state.ny.us/nysdoh/vital_statistics/2006/table38.htm 105

NUMBER OF DEATHS FROM LEADING CAUSES, RANKED WITHIN AGE GROUPS, BY GENDER, ORANGE COUNTY, 2004-2006 Number of Deaths Age Cause of Death Male Female Total < 10 Total Accidents 7 1 8 SIDS 5 1 6 Malignant Neoplasms 2 1 3 Homicide 0 1 1 Pneumonia 0 1 1 Other Causes 62 Total 81 10-19 Total Accidents 17 13 30 Suicide 6 1 7 Homicide 4 0 4 Diseases of the Heart 2 1 3 Malignant Neoplasms 0 1 1 Other Cause 25 Total 70 20-24 Total Accidents 18 5 23 Suicide 6 0 6 Diseases of the Heart 4 1 4 Homicide 1 0 1 Malignant Neoplasms 1 0 1 Other Causes 6 Total 43 25-44 Total Accidents 41 12 53 Malignant Neoplasms 23 29 52 Diseases of the Heart 37 11 48 Suicide 24 4 28 AIDS 11 3 14 Homicide 5 4 9 COPD 3 5 8 Stroke 4 4 8 Pneumonia 5 1 6 Diabetes 4 0 4 Septicemia 4 0 4 Cirrhosis 3 1 4 Other Causes 103 Total 341 Exhibit 1A.35 106

NUMBER OF DEATHS FROM LEADING CAUSES, RANKED WITHIN AGE GROUPS, BY GENDER, ORANGE COUNTY, 2004-2006 Number of Deaths Age Cause of Death Male Female Total 45-54 Malignant Neoplasms 82 76 158 Diseases of the Heart 81 24 105 Total Accidents 18 6 24 COPD 12 10 22 Cirrhosis 16 4 20 Suicide 14 1 15 AIDS 11 3 14 Septicemia 7 6 13 Cerebrovascular Disease 4 10 14 Diabetes 8 1 9 Pneumonia 3 2 5 Homicide 2 5 7 Other Causes 87 Total 493 55-64 Malignant Neoplasms 147 138 285 Diseases of the Heart 111 54 165 Diabetes 29 13 42 COPD 27 12 39 Cerebrovascular Disease 15 10 25 Septicemia 11 7 18 Pneumonia 12 5 17 Cirrhosis 13 3 16 Total Accidents 7 4 11 AIDS 4 0 4 Suicide 5 0 5 Homicide 2 0 2 Other Causes 144 Total 773 65-74 Malignant Neoplasms 245 214 459 Diseases of the Heart 156 115 271 COPD/CLRD 52 49 101 Diabetes 31 25 56 Cerebrovascular Disease 29 25 54 Septicemia 10 18 28 Pneumonia 17 11 28 Cirrhosis 8 11 19 Total Accidents 9 8 17 Homicide 2 0 2 Suicide 1 0 1 Other Causes 161 Total 1197 Exhibit 1A.35 107

NUMBER OF DEATHS FROM LEADING CAUSES, RANKED WITHIN AGE GROUPS, BY GENDER, ORANGE COUNTY, 2004-2006 Number of Deaths Age Cause of Death Male Female Total 75-84 Diseases of the Heart 290 316 606 Malignant Neoplasms 241 233 474 COPD/CLRD 68 88 156 Cerebrovascular Disease 49 59 108 Pneumonia 35 48 83 Septicemia 30 29 59 Diabetes 21 20 41 Total Accidents 9 8 17 Cirrhosis 3 9 12 Suicide 6 1 7 Homicide 1 0 1 Other Causes 363 Total 1927 85+ Diseases of the Heart 265 606 871 Malignant Neoplasms 107 195 302 Cerebrovascular Disease 45 110 155 COPD/CRLD 58 74 132 Pneumonia 37 81 118 Septicemia 16 37 53 Diabetes 13 23 36 Total Accidents 6 11 17 Cirrhosis 1 1 2 Other Causes 527 Total 2219 Includes 12 leading causes of death across all age groups. Ranked by numbers of deaths. Data does not include deaths recorded in New York City for this time period. COPD/CRLD = Chronic Obstructive Pulmonary Disease/Chronic Lower Respiratory Disease. Data source New York State DOH Vital Statistics Data Analysis by SUNY Albany School of Public Health. Exhibit 1A.35 108

HOSPITAL DISCHARGE RATE FOR AMBULATORY CARE SENSITIVE (ACS) CONDITIONS (AGE <5), ORANGE COUNTY, HUDSON VALLEY REGION AND NYS, 2004-2006 GASTROENTERITIS (AGE <5) DISCHARGE RATE PER 10,000 POPULATION, ORANGE COUNTY AND UPSTATE NY, TEN YEAR TIME TRENDS, 1997-2006 GASTROENTERITIS (AGE <5) DISCHARGE RATE PER 10,000 POPULATION Year Single Year Orange County 3-Year Average Orange County Upstate New York 1997 35.3 26.6 1998 40.1 44.3 23.6 1999 57.9 46.2 32.9 2000 40.5 57.2 21.4 2001 73.7 51.5 32.1 2002 40.3 55.8 23.8 2003 52.9 44.4 24.5 2004 40.2 47.2 21.4 2005 48.7 47.7 27 2006 54 22.2 GASTROENTERITIS (AGE <5) DISCHARGE RATE PER 10,000 POPULATION Discharges Population Region/County 2004 2005 2006 Total 2005 Rate Orange 102 124 139 365 25,467 47.8 Hudson Valley Region 317 395 356 1,068 146,053 24.4 New York State 3,683 4,524 3,985 12,192 1,249,101 32.5 Source: 2006-2007 SPARCS Data as of March, 2008 Exhibit 1A. 36a 109

HOSPITAL DISCHARGE RATE FOR AMBULATORY CARE SENSITIVE (ACS) CONDITIONS (AGE <5), ORANGE COUNTY, HUDSON VALLEY REGION AND NYS, 2004-2006 OTITIS MEDIA (AGE <5) DISCHARGE RATE PER 10,000 POPULATION, ORANGE COUNTY AND UPSTATE NY, TEN YEAR TIME TRENDS, 1997-2006 OTITIS MEDIA (AGE <5) DISCHARGE RATE PER 10,000 POPULATION, 1997-2006 Year Single Year Orange County 3-Year Average Orange County Upstate New York 1997 20.5 5.9 1998 15.7 17.5 5.4 1999 16.2 15 6 2000 13.1 13.2 5 2001 10.3 12.9 3.8 2002 15.3 10.9 4.2 2003 7 8.6 3.9 2004 3.5 3.7 2.9 2005 0.8 2 3.2 2006 1.6 2.2 OTITIS MEDIA (AGE <5) DISCHARGE RATE PER 10,000 POPULATION Discharges Population Region/County 2004 2005 2006 Total 2005 Rate Orange 9 2 4 15 25,467 2 Hudson Valley Region 36 31 28 95 146,053 2.2 New York State 553 532 428 1,513 1,249,101 4 Source: 2006-2007 SPARCS Data as of March, 2008 Exhibit 1A. 36b 110

HOSPITAL DISCHARGE RATE FOR AMBULATORY CARE SENSITIVE (ACS) CONDITIONS (AGES 5-14), ORANGE COUNTY, HUDSON VALLEY REGION AND NYS, 2004-2006 ASTHMA (AGES 5-14) DISCHARGE RATE PER 10,000 POPULATION, ORANGE COUNTY AND UPSTATE NY, TEN YEAR TIME TRENDS, 1997-2006 ASTHMA (AGES 5-14) DISCHARGE RATE PER 10,000 POPULATION, 1997-2006 Year Single Year Orange County 3-Year Average Orange County Upstate New York 1997 19.9 15.5 1998 11 15.6 11.9 1999 15.8 15 12.5 2000 18.1 15.7 11.7 2001 13.2 15.2 9.8 2002 14.3 15.1 9.4 2003 17.9 14.7 12.1 2004 12.1 15.1 11 2005 15.3 14.8 11 2006 17.1 11.2 ASTHMA (AGES 5-14) DISCHARGE RATE PER 10,000 POPULATION Discharges Population Region/County 2004 2005 2006 Total 2005 Rate Orange 70 87 95 252 56,832 14.8 Hudson Valley Region 364 363 363 1,090 315,460 11.5 New York State 6,436 5,633 5,445 17,514 2,495,085 23.4 Source: 2006-2007 SPARCS Data as of March, 2008 Exhibit 1A. 36c 111

HOSPITAL DISCHARGE RATE FOR AMBULATORY CARE SENSITIVE (ACS) CONDITIONS (AGE <5), ORANGE COUNTY, HUDSON VALLEY REGION AND NYS, 2004-2006 ASTHMA (AGE <5) DISCHARGE RATE PER 10,000 POPULATION, ORANGE COUNTY AND UPSTATE NY, TEN YEAR TIME TRENDS, 1997-2006 ASTHMA (AGE <5) DISCHARGE RATE PER 10,000 POPULATION, 1997-2006 Year Single Year Orange County 3-Year Average Orange County Upstate New York 1997 53.2 41.2 1998 36.3 48.7 33.2 1999 56.7 46.4 41.3 2000 46.3 52.7 34.4 2001 55.1 51.2 37.5 2002 52.4 57.5 35.9 2003 65.3 57 42.6 2004 53.6 54.8 39 2005 45.9 48.7 36.3 2006 46.7 38.4 ASTHMA (AGE <5) DISCHARGE RATE PER 10,000 POPULATION Discharges Population Region/County 2004 2005 2006 Total 2005 Rate Orange 136 117 120 373 25,467 48.8 Hudson Valley Region 575 527 530 1,632 146,053 37.2 New York State 8,405 7,284 7,432 23,121 1,249,101 61.7 Source: 2006-2007 SPARCS Data as of March, 2008 Exhibit 1A. 36d 112

HOSPITAL DISCHARGE RATE FOR AMBULATORY CARE SENSITIVE (ACS) CONDITIONS (AGE <5), ORANGE COUNTY, HUDSON VALLEY REGION AND NYS, 2004-2006 PNEUMONIA (AGE <5) DISCHARGE RATE PER 10,000 POPULATION, ORANGE COUNTY AND UPSTATE NY, TEN YEAR TIME TRENDS, 1997-2006 PNEUMONIA (AGE <5) DISCHARGE RATE PER 10,000 POPULATION, 1997-2006 Year Single Year Orange County 3-Year Average Orange County Upstate New York 1997 69.9 38.1 1998 51.9 60.4 38.2 1999 59 58.2 40.1 2000 63.7 63.3 42.3 2001 67.4 64.4 41 2002 62 62.5 39.2 2003 57.9 57.5 41.2 2004 52.8 54.4 39.6 2005 52.6 53.2 37.8 2006 54 39.2 PNEUMONIA (AGE <5) DISCHARGE RATE PER 10,000 POPULATION Discharges Population Region/County 2004 2005 2006 Total 2005 Rate Orange 134 134 139 407 25,467 53.3 Hudson Valley Region 554 518 567 1,639 146,053 37.4 New York State 5,641 5,422 5,722 16,785 1,249,101 44.8 Source: 2006-2007 SPARCS Data as of March, 2008 Exhibit 1A. 36e 113

Source: New York State Department of Health 2004-2005 Lead Surveillance Report Exhibit 1A. 37 114

Source: New York State Department of Health 2004-2005 Lead Surveillance Report Exhibit 1A. 38 115

SELECTED KIDS' WELL-BEING INDICATORS, ORANGE COUNTY AND REST OF STATE, 2003-2007 NUMBER AND* RATE OF YOUNG ADULT ARRESTS-DRUG USE/POSSESION/SALE AGES 16-21 YEARS, ORANGE COUNTY AND REST OF STATE, 2003-2007 Region 2003 2004 2005 2006 2007 Number Rate/10,000 Number Rate/10,000 Number Rate/10,000 Number Rate/10,000 Number Rate/10,000 Rest of State 8,440 89 8,568 90.2 8,490 88.6 9,831 101.3 8,980 91.7 Orange County 337 103.6 429 130.6 415 123.4 478 138.5 380 107.4 *Rate per 10,000 young adults age 16-21 NUMBER AND RATE* OF YOUNG ADULT PROPERTY CRIMES AGES 16-21 YEARS, ORANGE COUNTY AND REST OF STATE, 2003-2007 Region 2003 2004 2005 2006 2007 Number Rate/10,000 Number Rate/10,000 Number Rate/10,000 Number Rate/10,000 Number Rate/10,000 Rest of State 16,321 172.1 15,925 167.7 15,800 164.9 15,884 163.7 16,406 167.6 Orange County 780 239.8 656 199.8 655 197.8 736 213.3 716 202.4 *Rate per 10,000 young adults age 16-21 NUMBER AND RATE* OF YOUNG ADULT ARRESTS- VIOLENT CRIMES AGES 16-21 YEARS, ORANGE COUNTY AND REST OF STATE, 2003-2007 Region 2003 2004 2005 2006 2007 Number Rate/10,000 Number Rate/10,000 Number Rate/10,000 Number Rate/10,000 Number Rate/10,000 Rest of State 5,082 53.6 4,958 52.2 5,386 56.2 5,692 58.7 5,014 51.2 Orange County 175 53.8 198 60.3 199 59.2 240 69.5 211 59.7 *Rate per 10,000 young adults age 16-21 NUMBER AND RATE* OF YOUNG ADULTS DRIVING WHILE INTOXICATED, AGES 16-21 YEARS, ORANGE COUNTY AND REST OF STATE, 2003-2007 Region 2003 2004 2005 2006 2007 Number Rate/10,000 Number Rate/10,000 Number Rate/10,000 Number Rate/10,000 Number Rate/10,000 Rest of State 6,312 66.6 6,642 69.69 6,570 68.6 6,717 69.2 6,449 65.9 Orange County 246 75.6 259 78.9 250 74.4 272 78.8 282 79.7 *Rate per 10,000 young adults age 16-21 NUMBER AND RATE OF CHILDREN/YOUTH IN INDICATED REPORTS OF ABUSE/MALTREATMENT, AGES 0-17 YEARS, ORANGE COUNTY AND REST OF STATE, 2003-2007 Region 2003 2004 2005 2006 2007 Number Rate/1,000 Number Rate/1,000 Number Rate/1,000 Number Rate/1,000 Number Rate/1,000 Rest of State 39,260 14.4 41,215 15.2 40,735 15 41,913 15.5 42,286 15.8 Orange County 1,216 11.9 1,248 12.2 1,051 10.2 1,146 11.1 1,090 10.5 *Rate per 1,000 young children ages 0-17 years NUMBER AND PERCENT OF INDICATED REPORTS OF ABUSE/MALTREATMENT, ORANGE COUNTY AND REST OF STATE, 2003-2007 Region 2003 2004 2005 2006 2007 Number Percent Number Percent Number Percent Number Percent Number Percent Rest of State 26,800 28.3 26,922 29.3 26,257 29.2 27,204 28.7 27,119 28.3 Orange County 77 28.7 801 30.4 645 26.8 668 25.7 664 24.5 Source: Kids' Well-Being Indicators Clearinghouse http://www.nyskwic.org/ Exhibit 1A.39 116

EARLY CHILDHOOD (AGE 1-4) - DEATHS AND DEATH RATES PER 100,000 RESIDENTS, ORANGE COUNTY, HUDSON VALLEY REGION, AND NYS, 2004-2006 Deaths Population Crude Region/County 2004 2005 2006 Total 2005 Rate Orange 3 7 1 11 20,223 18.1 Hudson Valley Region 23 32 16 71 116,538 20.3 New York State 209 219 214 642 997,236 21.5 CHILDHOOD/ADOLESCENT(AGE 5-14) - DEATHS AND DEATH RATES PER 100,000 RESIDENTS Deaths Population Crude Region/County 2004 2005 2006 Total 2005 Rate Orange 5 8 8 21 56,832 12.3 Hudson Valley Region 37 29 25 91 315,460 9.6 New York State 347 326 265 938 2,495,085 12.5 ADOLESCENT/YOUNG ADULT (AGE 15-19) - DEATHS AND DEATH RATES PER 100,000 RESIDENTS Deaths Population Crude Region/County 2004 2005 2006 Total 2005 Rate Orange 18 22 10 50 29,417 56.7 Hudson Valley Region 77 64 60 201 161,827 41.4 New York State 594 572 594 1,760 1,318,372 44.5 Source: 2004-2006 NYSDOH Vital Statistics Data as of March, 2008 Exhibit 1A.40 117

SUICIDE AND SELF-INFLICTED INJURY MORTALITY AND HOSPITAL DISCHARGE RATES (ALL AGES, AGES 15-19), ORANGE COUNTY, HUDSON VALLEY REGION AND NEW YORK STATE, 2004-2006 SUICIDE - DEATHS AND DEATH RATES PER 100,000 RESIDENTS Deaths Population Crude Adjusted Region/County 2004 2005 2006 Total 2005 Rate Rate Orange 28 22 17 67 372,893 6 6.1 Hudson Valley Region 112 127 126 365 2,261,204 5.4 5.3 New York State 1,196 1,298 1,295 3,789 19,254,630 6.6 6.4 ADOLESCENT/YOUNG ADULT SUICIDE (AGES 15-19) - DEATHS AND DEATH RATES PER 100,000 RESIDENTS Deaths Population Crude Adjusted Region/County 2004 2005 2006 Total 2005 Rate Rate Orange 2 1 2 5 29,417 5.7 6.1 Hudson Valley Region 11 5 6 22 161,827 4.5 5.3 New York State 68 56 51 175 1,318,372 4.4 6.4 SELF-INFLICTED INJURY - DISCHARGE RATE PER 100,000 POPULATION Deaths Population Crude Region/County 2004 2005 2006 Total 2005 Rate Orange 210 209 207 626 372,893 5.6 Hudson Valley Region 1,120 1,050 1,066 3,236 2,261,204 4.8 New York State 9,468 9,638 9,537 28,643 19,254,630 5 SELF-INFLICTED INJURY (AGES 15-19) - DISCHARGE RATE PER 100,000 POPULATION AGE Deaths Population Crude Region/County 2004 2005 2006 Total 2005 Rate Orange 28 35 33 96 29,417 10.9 Hudson Valley Region 178 172 172 522 161,827 10.8 New York State 1,330 1,224 1,273 3,827 1,318,372 9.7 Source: 2004-2006 Sparcs Data As Of March, 2008 Adjusted rates are age adjusted to the 2000 United States Population Exhibit 1A. 41 118

TEENAGE PREGNANCY RATES BY AGE GROUP (10-14), ORANGE COUNTY AND UPSTATE NY, TEN YEAR TIME TRENDS 1997-2006 TEENAGE (AGES 10-14) PREGNANCY RATE PER 1,000 FEMALES AGE Year Single Year 3-Year Average Orange Upstate New Orange County County York 1997 1.6 1.4 1998 1.2 1.2 1.1 1999 0.8 1.1 1 2000 1.4 1.1 1 2001 1.2 1.3 1 2002 1.4 1 1 2003 0.4 1 0.9 2004 1.2 0.7 0.9 2005 0.7 0.9 0.9 2006 0.8 0.9 TEENAGE PREGNANCIES (AGES 10-14) - RATE PER 1,000 FEMALES Pregnancies (Age 10-14) 14) Population Rate Region/County 2004 2005 2006 Total 2005 Orange 17 10 12 39 14,383 0.9 Hudson Valley Region 76 65 61 202 80,231 0.8 New York State 1,049 984 896 2,929 636,663 1.5 Source: 2004-2006 NYSDOH Vital Statistics Data as of March, 2008 Exhibit 1A. 42a 119

TEENAGE PREGNANCY RATES BY AGE GROUP (15-17), ORANGE COUNTY AND UPSTATE NY, TEN YEAR TIME TRENDS 1997-2006 TEENAGE (AGES 15-17) PREGNANCY RATE PER 1,000 FEMALES Year Single Year Orange County 3-Year Average Orange County Upstate New York 1997 41.1 34.6 1998 36 37.5 32.4 1999 35.5 34.6 30.7 2000 32.4 33.1 29.8 2001 31.6 30.5 27.9 2002 27.7 27.5 26.3 2003 23.5 24.7 24.8 2004 23.1 24.6 23.4 2005 26.9 25.8 23.3 2006 27.3 24.3 TEENAGE PREGNANCIES (AGES 15-17) - RATE PER 1,000 FEMALES Pregnancies (Age 15-17) Populatio Rate Region/County 2004 2005 2006 Total 2005 Orange 197 239 245 681 8,882 25.6 Hudson Valley Region 983 1,193 1,193 3,369 48,891 23 New York State 14,285 14,256 14,446 42,987 390,618 36.7 Source: 2004-2006 NYSDOH Vital Statistics Data as of March, 2008 Exhibit 1A. 42b 120

TEENAGE PREGNANCY RATES BY AGE GROUP (15-19), ORANGE COUNTY AND UPSTATE NY, TEN YEAR TIME TRENDS 1997-2006 TEENAGE (AGES 15-19) PREGNANCY RATE PER 1,000 FEMALES AGE Year Single Year Orange County 3-Year Average Orange County Upstate New York 1997 68.6 55.4 1998 63.3 64.8 52.7 1999 62.7 61.4 51.1 2000 58.5 60.2 49.7 2001 59.6 56.2 47.4 2002 50.9 52.1 44.8 2003 46 47.1 43 2004 44.7 45.7 40.8 2005 46.4 45.5 41 2006 45.3 41.6 TEENAGE PREGNANCIES (AGES 15-19) - RATE PER 1,000 FEMALES Pregnancies (Age 15-19) Population Region/County 2004 2005 2006 Total 2005 Orange 597 626 639 1,862 13,492 46 Hudson Valley Region 2,810 3,212 3,380 9,402 77,755 40.3 New York State 39,236 39,036 40,121 118,393 643,315 61.3 Rate Source: 2004-2006 NYSDOH Vital Statistics Data as of March, 2008 Exhibit 1A. 42c 121

INDUCED TERMINATION OF PREGNANCY TO PREGNANCY RATIO PER 100 LIVE BIRTHS (ALL AGES) ORANGE COUNTY, UPSTATE NEW YORK, TEN YEAR TIME TRENDS 1997-2006 INDUCED TERMINATION OF PREGNANCY TO PREGNANCY RATIO PER 100 LIVE BIRTHS (ALL AGES) Single Year 3-Year Average Upstate Year Orange County Orange County New York 1997 32.6 29.7 1998 31.2 31.2 27 1999 29.7 30 27 2000 29.1 30.5 26.3 2001 32.5 30.7 26.9 2002 30.5 29.7 27.5 2003 26.1 27.9 26 2004 27.2 27.3 26.7 2005 28.5 28.5 27.4 2006 29.7 29.4 INDUCED TERMINATION OF PREGNANCY TO PREGNANCY RATIO PER 100 LIVE BIRTHS (ALL AGES) ITOP (All Ages) Population Rate Region/County 2004 2005 2006 Total 2005 Orange 1,416 1,474 1,613 4,503 15,804 28.5 Hudson Valley Region 6,572 8,609 9,242 24,423 86,771 28.1 New York State 120,401 117,944 121,278 359,623 743,559 48.4 Rate per 100,000 population Source: 2004-2006 Vital Statistics Data As Of April, 2008 Exhibit 1A. 43 122

TEENAGE BIRTHS BY AGE GROUP (10-14), ORANGE COUNTY AND UPSTATE NEW YORK, TEN YEAR TIME TREND, 1997-2006 TEENAGE (AGES 10-14) BIRTH RATE PER 1,000 FEMALES AGE Year Single Year Orange County 3-Year Average Orange County Upstate New York 1997 0.8 0.5 1998 0.6 0.6 0.4 1999 0.5 0.5 0.5 2000 0.4 0.5 0.4 2001 0.6 0.5 0.4 2002 06 0.6 05 0.5 04 0.4 2003 0.1 0.4 0.3 2004 0.4 0.3 0.3 2005 0.3 0.3 0.3 2006 0.2 0.3 TEENAGE (AGES 10-14) BIRTH RATE PER 1,000 FEMALES Births Age (10-14) Population Rate Region/County 2004 2005 2006 Total 2005 Orange 6 4 3 13 14,383 0.3 Hudson Valley Region 19 15 12 46 80,231 0.2 New York State 271 259 220 750 636,663 0.4 Source: 2004-2006 NYSDOH Vital Statistics Data as of April, 2008 Exhibit 1A. 44a 123

TEENAGE BIRTHS BY AGE GROUP (15-17), ORANGE COUNTY AND UPSTATE NEW YORK, TEN YEAR TIME TREND 1997-2006 TEENAGE BIRTHS (AGES 15-17) - PERCENTAGE PER 1000 LIVE BIRTHS Year Single Year Orange County 3-Year Average Orange County Upstate New York 1997 18 17.2 1998 16.8 17.3 16.9 1999 17.1 16.2 16 2000 14.9 15.2 15.2 2001 13.7 12.8 13.9 2002 9.9 11.7 12.6 2003 11.5 10.4 12 2004 10 11.1 11.3 2005 11.8 10.3 10.9 2006 9.2 10.6 TEENAGE (AGES 15-17) BIRTH RATE PER 1,000 FEMALES Births Age (15-17) Population Rate Region/County 2004 2005 2006 Total 2005 Orange 85 105 83 273 8,882 10.2 Hudson Valley Region 423 439 399 1,261 48,891 8.6 New York State 5,417 5,332 5,216 15,965 390,618 13.6 Source: 2004-2006 NYSDOH Vital Statistics Data as of April, 2008 Exhibit 1A. 44b 124

TEENAGE BIRTHS BY AGE GROUP (15-19), ORANGE COUNTY AND UPSTATE NEW YORK, TEN YEAR TIME TREND 1997-2006 TEENAGE (AGES 15-19) BIRTH RATE PER 1,000 FEMALES Year Single Year Orange County 3-Year Average Orange County Upstate New York 1997 34.9 29.7 1998 32.1 33.5 29.6 1999 33.4 31.6 28.8 2000 29.2 30.8 27.6 2001 29.8 27.8 26 2002 24.5 26.4 24.4 4 2003 25.2 24.3 23.3 2004 23.3 24.1 21.8 2005 23.9 22.8 22 2006 21.2 21.7 TEENAGE (AGES 15-19) BIRTH RATE PER 1,000 FEMALES Births Age (15-19) Population Rate Region/County 2004 2005 2006 Total 2005 Orange 309 323 299 931 13,492 23 Hudson Valley Region 1,439 1,488 1,507 4,434 77,755 19 New York State 17,031 17,036 17,405 51,472 643,315 26.7 Source: 2004-2006 NYSDOH Vital Statistics Data as of April, 2008 Exhibit 1A. 44c 125

TEENAGE BIRTHS (AGE 15-17) - PERCENTAGE OF LIVE BIRTHS, ORANGE COUNTY AND UPSTATE NEW YORK, TEN YEAR TIME TRENDS 1997-2006 TEENAGE BIRTHS (AGES 15-17) - PERCENTAGE OF LIVE BIRTHS PER 100 BIRTHS Year Single Year Orange County 3-Year Average Orange County Upstate New York 1997 2.6 2.7 1998 2.5 2.6 2.7 1999 2.6 2.5 2.6 2000 2.3 2.3 2.4 Source: 2004-2006 NYSDOH Vital Statistics Data as of April, 2008 2001 2.1 2 2.3 2002 1.5 1.8 2.1 2003 18 1.8 17 1.7 2 2004 1.6 1.8 2 2005 2 1.7 2 2006 1.5 2 TEENAGE BIRTHS (AGES 15-17) BIRTH PERCENTAGE PER 100 LIVE BIRTHS Births Age (15-17) Births Rate Region/County 2004 2005 2006 Total 2004-2006 2006 Orange 85 105 83 273 15,801 1.7 Hudson Valley Region 423 439 399 1,261 86,753 1.5 New York State 5,417 5,332 5,216 15,965 744,261 2.1 Source: 2004-2006 NYSDOH Vital Statistics Data as of April, 2008 Exhibit 1A. 45 126

BIRTHS TO TEEN MOTHERS (17 YEARS AND YOUNGER) PER 100 LIVE BIRTHS BY RACE, ETHNICITY, AGE, AND ZONE, ORANGE COUNTY, 1998-2006 1998-2000 2001-2003 2004-2006 Total Percent of Total Percent of Total Percent of Number Births Total Births Number Births Total Births Number Births Total Births Total County* 380 14,191 2.68% 292 13,864 2.11% 286 14,728 1.94% HV Region** 1,678 89,852 1.87% 1,360 88,373 1.54% 1,307 86,793 1.51% Upstate NY** 10,999 411,300 2.67% 9,065 400,511 2.26% 8,076 388,419 2.08% Race/ Ethnicity White 253 12,622 2.00% 227 12,177 1.86% 122 10,829 1.13% Black 123 1,220 10.08% 77 1,233 6.24% 67 1,311 5.11% Other s/n 313 s/n s/n 328 s/n 99 2579 3.84% Hispanic 130 2,166 6.00% 118 2,545 4.64% 103 2,318 4.44% Age 10-14 20 20 19 19 13 13 15-17 360 360 273 273 273 273 18+ 13,811 13,553 14,712 Zones Central 33 4,471 0.74% 21 4,139 0.51% 24 4,570 0.53% East 54 3,179 1.70% 30 3,272 0.92% 31 3,258 0.95% Middletown City 64 1,466 4.37% 70 1,732 4.04% 73 2,259 3.23% Newburgh City 166 1,875 8.85% 120 1,889 6.35% 115 2,090 5.50% North 25 1094 2.29% 13 900 1.44% 10 641 1.56% Port Jervis City 18 501 3.59% 16 447 3.58% 20 553 3.62% West 20 1,605 1.25% 22 1,485 1.48% 13 1,357 0.96% *Births recorded in NYC for Orange County residents are not included in this analysis by county or zone. **Includes births to Orange County residents recorded in New York City. s/n=data are unreliable due to small number of cases Rates are based on births with known risk factor information. Data Source: NYS DOH Vital Statistics Created by the School of Public Health, University at Albany, August, 2009 Exhibit 1A.46a 127

BIRTHS TO TEEN MOTHERS (17 YEARS AND YOUNGER) PER 100 LIVE BIRTHS BY RACE, ETHNICITY, AGE, AND ZONE, ORANGE COUNTY, 2004-2006 2004 2005 2006 Number Total Percent of Number Total Percent of Number Total Percent of Births Total Births Births Total Births Births Total Births Total Orange County* 91 4,825 1.91% 108 4,847 2.17% 87 5,056 1.74% HV Region** 442 29,166 1.51% 454 28,737 1.57% 411 28,890 1.40% Upstate NY** 2,729 130,351 2.00% 2,697 128,316 2.10% 2,650 129,752 2.04% Race/ Ethnicity White 46 3,666 1.25% 52 3,701 1.41% 24 3,462 0.69% Black 25 413 6.05% 25 446 5.60% s/n 452 s/n Other 21 743 2.83% 31 697 4.47% 47 1,139 4.13% Hispanic 30 714 4.20% 36 747 4.82% 37 857 4.14% Age 10-14 6 6 s/n s/n s/n s/n 15-17 85 85 104 104 84 84 18+ 4,818 4,738 4,960 Zones Central 9 1,476 0.61% 9 1,502 0.60% 6 1,592 0.38% East s/n 1,061 s/n s/n 1,077 s/n s/n 1,120 s/n Middletown City 29 764 3.80% 26 755 3.44% s/n 740 s/n Newburgh City 33 735 4.49% 41 664 6.17% 41 691 5.93% North s/n 180 s/n s/n 213 s/n s/n 248 s/n Port Jervis City 11 177 6.21% 6 185 3.24% s/n 191 s/n West s/n 432 s/n 6 451 1.33% s/n 474 s/n *Data at county and zone levels does not contain births recorded in NYC. **Contains data recorded in NYC for Orange County residents. s/n = data are unreliable due to small number of cases Rates are based on births with known risk factor information Data Source: NYS DOH Vital Statistics. Vital records for events in 2001 and 2002 registered in New York City are not yet incorporated into this analysis. Created by the School of Public Health, University at Albany, August 2009 Exhibit 1A.46b 128

BIRTHS TO MOTHERS 17 YEARS AND YOUNGER, ORANGE COUNTY, HUDSON VALLEY, AND UPSTATE NY 1998-2006 0.03 0.025 0.02 Rate 0.015 0.01 0.005 0 1998-2000 2001-2003 2004-2006 Time Period County HV Region Upstate Rates per 100 live births Data Source: NYS DOH Vital Statistics Created by the School of Public Health, University at Albany, August, 2009 Exhibit 1A.46c 129

BIRTHS TO MOTHERS 17 YEARS AND YOUNGER, ORANGE COUNTY, 1998-2006 Percentage 0.1 0.09 0.08 0.07 0.06 0.05 0.04 0.03 0.02 0.01 1998-2000 2001-2003 2004-2006 0 Central Middletown City North West Health Planning Zone Rates per 100 live births Data Source: NYS DOH Vital Statistics Created by the School of Public Health, University at Albany, August, 2009 Exhibit 1A.46d 130

MEDICAID/SELF PAY BIRTHS PERCENTAGE PER 100 LIVE BIRTHS, BY RACE, ETHNICITY, AGE AND ZONES, ORANGE COUNTY, HUDSON VALLEY REGION AND UPSTATE NY, 1998-2006 1998-2000 2001-2003 2004-2006 Number Total Percent of Number Total Percent of Number Total Percent of Medicaid Births Total Births Medicaid Births Total Births Medicaid Births Total Births Total Orange County 3,969 11,619 34.16% 4,561 13,032 35.00% 5,542 14,254 38.88% HV Region 21,380 89,852 23.79% 28,735 88,373 32.52% 28,829 86,793 33.22% Upstate NY 100,808 411,300 24.51% 100,921 400,511 25.20% 114,198 388,419 29.40% Race/ Ethnicity White 3,338 10,321 32.34% 3,810 11,441 33.30% 3,356 10,402 32.26% Black 557 1,022 54.50% 648 1,189 54.50% 658 1,299 50.65% Other 67 251 26.69% 84 293 28.67% 1527 2550 59.88% Hispanic 1,211 1,925 62.91% 1,594 2,488 64.07% 1,615 2,294 70.40% Age 10-14 11 16 68.75% 15 18 83.33% 9 13 69.23% 15-17 222 304 73.03% 188 268 70.15% 184 271 67.90% 18-19 457 626 73.00% 490 661 74.13% 457 623 73.35% 20-24 1,571 2,467 63.68% 1,725 2,680 64.37% 2,126 3035 70.05% 25-44 1,706 8,195 20.82% 2,142 9,387 22.82% 2,764 10289 26.86% 45+ s/n 11 s/n s/n 18 s/n 23 s/n Zones Central 971 3,231 30.05% 1,179 3,884 30.36% 1,807 4,301 42.01% East 458 2,505 18.28% 542 2,937 18.45% 587 3,195 18.37% Middletown City 664 1,412 47.03% 806 1,698 47.47% 1096 2,229 49.17% Newburgh City 1,073 1,572 68.26% 1,345 1,872 71.85% 1,404 2,079 67.53% North 279 1043 26.75% 218 872 25.00% 167 637 26.22% Port Jervis City 271 480 56.46% 239 431 55.45% 261 543 48.07% West 253 1,376 18.39% 232 1,338 17.34% 220 1,270 17.32% Included in Medicaid/Self-pay births are those mothers on other government insurance including Child Health Plus and Family Health Plus. HV = Hudson Valley s/n= data are unreliable due to small number of cases Rates are based on births with known information on primary source of payment. Data Source: NYS DOH Vital Statistics. Vital records for events recorded in NYC are not included in this analysis by county. Created by the School of Public Health, University at Albany, August, 2009 Exhibit 1A.47a 131

MEDICAID/SELF PAY BIRTHS PERCENTAGE PER 100 LIVE BIRTHS, BY RACE, ETHNICITY, AGE AND ZONES, ORANGE COUNTY, HUDSON VALLEY REGION AND UPSTATE NY, 2004-2006 2004 2005 2006 Number Medicaid Total Births Percent of Total Births Number Medicaid Total Births Percent of Total Births Number Medicaid Total Births Percent of Total Births Total Orange County* 1,722 4,706 36.59% 1,801 4,685 38.44% 2,019 4,863 41.52% HV Region** 8,946 29,166 30.67% 9,742 28,737 33.90% 10,141 28,890 35.10% Upstate NY** 35,535 130,351 27.26% 38,133 128,316 29.72% 40,530 129,752 31.24% Race/ Ethnicity White 1,053 3,558 29.60% 1,204 3,560 33.82% 1,099 3,284 33.47% Black 225 412 54.61% 211 437 48.28% 222 450 49.33% Other 443 735 60.27% 386 687 56.19% 698 1,128 61.88% Hispanic 511 710 71.97% 520 738 70.46% 584 846 69.03% Age 10-14 s/n 6 s/n s/n s/n s/n s/n s/n s/n 15-17 65 85 76.47% 63 102 61.76% 56 84 66.67% 18-19 156 211 73.93% 150 204 73.53% 151 208 72.60% 20-24 679 1,003 67.70% 712 1,011 70.43% 735 1,021 71.99% 25-44 817 3,395 24.06% 872 3,355 25.99% 1,075 3,539 30.38% 45+ 0 6 0.00% s/n 9 s/n s/n 8 s/n Zones Central 470 1,412 33.29% 608 1,419 42.85% 729 1,470 49.59% East 201 1,047 19.20% 185 1,050 17.62% 201 1,098 18.31% Middletown City 355 758 46.83% 365 739 49.39% 376 732 51.37% Newburgh City 496 732 67.76% 439 660 66.52% 469 687 68.27% North 49 179 27.37% 52 212 24.53% 66 246 26.83% Port Jervis City 76 174 43.68% 85 181 46.96% 100 188 53.19% West 75 404 18.56% 67 424 15.80% 78 442 17.65% *Data at county and zone levels does not contain births recorded in NYC. **Contains data recorded in NYC for Orange County residents. HV = Hudson Valley s/n= data are unreliable due to small number of cases Included in Medicaid/Self-pay births are those mothers on other government insurance including Child Health Plus and Family Health Plus. Rates are based on births with known information on primary source of payment Data Source: NYS DOH Vital Statistics. Created by the School of Public Health, University at Albany, August,2009 Exhitbit 1A.47b 132

MEDICAID/SELF-PAY BIRTHS IN ORANGE COUNTY, HUDSON VALLEY REGION, UPSTATE NY, 1998-2006 45.00% 40.00% 35.00% Percent of Live Births 30.00% 25.00% 20.00% 15.00% 10.00% 5.00% 0.00% 1998-2000 2001-2003 2004-2006 Time Period Orange County HV Region Upstate NY Rate per 100 live births Data at county level does not include births to Orange County residents recorded in NYC. Included in Medicaid/Self-pay births are those births covered by Family Health Plus and Child Health Plus. Data were obtained from New York State DOH Department of Vital Statistics. Created by the SUNY Albany School of Public Health, August 2009 Exhibit 1A.47c 133

MEDICAID/SELF-PAY BIRTHS IN ORANGE COUNTY BY ZONE, 1998-2006 0.8 0.7 0.6 0.5 0.4 Rate 0.3 0.2 0.1 0 Central East Middletown City Newburgh City North Port Jervis City West Health Planning Zones 1998-2000 2001-2003 2004-2006 Rate per 100 live births Data at county level does not include births to Orange County residents recorded in NYC. Included in Medicaid/Self-pay births are those births covered by Family Health Plus and Child Health Plus. Data were obtained from New York State DOH Department of Vital Statistics. Created by the SUNY Albany School of Public Health, August 2009 Exhibit 1A.47d 134

MEDICAID/SELF-PAY BIRTH PERCENTRAGE PER 100 LIVE BIRTHS: TEN YEAR TIME TRENDS, ORANGE COUNTY, UPSTATE NY, 1997-2006 MEDICAID/SELF-PAY BIRTHS - PERCENTAGE PER 100 LIVE BIRTHS Year Single Year Orange County 3-Year Average Orange County Upstate New York 1997 35.1 27.9 1998 34.5 34.5 27.5 1999 33.8 34.5 27.3 2000 35.2 34.5 27.1 2001 34.4 35.3 27.6 2002 36.1 36.1 28 2003 37.5 36.8 28.7 2004 36.9 37.5 29.8 2005 38.1 37.9 32.1 2006 38.8 33.3 Source: 2004-2006 NYSDOH Vital Statistics Data as of April, 2008 MEDICAID/SELF-PAY BIRTHS - PERCENTAGE PER 100 LIVE BIRTHS Births Births Rate Region/County 2004 2005 2006 Total 2004-2006 Orange 1,722 1,801 2,013 5,536 14,717 37.6 Hudson Valley Region 8,813 9,599 10,327 28,739 78,538 36.6 New York State 38,006 40,214 42,952 121,172 383,540 31.6 Exhibit 1A. 47e 135

BIRTHS WITH EARLY (FIRST TRIMESTER) PRENATAL CARE, BY RACE, ETHNICITY, AGE GROUP AND HEALTH PLANNING ZONE, ORANGE COUNTY, HUDSON VALLEY REGION, AND UPSTATE NY, 2004-2006 Number 2004 2005 2006 Total Percent of Total Percent of Total Number Number Births Total Births Births Total Births Births Percent of Total Births Total Orange County* 3,094 4,383 70.59% 2,817 4,162 67.68% 2,816 4,156 67.76% HV Region** 16,614 29,166 56.96% 18,756 28,737 65.27% 17,712 28,890 61.31% Upstate NY** 92,006 103,351 89.02% 92,113 128,316 71.79% 90,806 129,752 69.98% Race/ Ethnicity White 2,439 3,337 73.09% 2,257 3,238 69.70% 1,961 2,802 69.99% Black 207 368 56.25% 214 354 60.45% 246 376 65.43% Other 448 678 66.08% 345 569 60.63% 609 978 62.27% Hispanic 446 673 66.27% 371 649 57.16% 467 728 64.15% Age 10-14 s/n s/n s/n s/n s/n s/n s/n s/n s/n 15-17 35 82 42.68% 31 87 35.63% 31 64 48.44% 18-19 105 190 55.26% 78 181 43.09% 96 180 53.33% 20-24 536 945 56.72% 477 870 54.83% 479 854 56.09% 25-44 2,415 3,159 76.45% 2,225 3,011 73.90% 2,206 3,051 72.30% 45+ s/n s/n s/n s/n 9 s/n s/n 6 s/n Zones Central 927 1,336 69.39% 773 1,232 62.74% 700 1,139 61.46% East 709 919 77.15% 751 955 78.64% 754 974 77.41% Middletown City 489 732 66.80% 423 696 60.78% 426 705 60.43% Newburgh City 421 669 62.93% 320 515 62.14% 349 522 66.86% North 124 171 72.51% 131 197 66.50% 152 231 65.80% Port Jervis City 115 172 66.86% 104 166 62.65% 109 170 64.12% West 309 384 80.47% 315 401 78.55% 326 415 78.55% *Births to Orange County residents recorded in NYC are not included in this analysis. ** Includes births registered in NYC. HV = Hudson Valley s/n=data are unreliable due to small number of cases Rates are based on births with known risk factor information. Data Source: NYS DOH Vital Statistics. Created by the School of Public Health, University at Albany, August, 2009 Exhibit 1A.48a 136

BIRTHS WITH EARLY (FIRST TRIMESTER) PRENATAL CARE, BY RACE, ETHNICITY, AGE AND ZONE, ORANGE COUNTY, 1998-2006 1998-2000 2001-2003 2004-2006 Number Total Percent of Number Total Percent of Number Total Percent of Births Total Births Births Total Births Births Total Births Total Orange County* 9,332 12,856 72.59% 8,585 12,749 67.34% 8,727 12,701 68.71% HV Region** 59,662 85,204 70.02% 58,242 85,423 68.18% 52,865 86,793 60.91% Upstate NY** 308,226 411,300 74.94% 291,786 400,511 72.85% 274,925 388,419 70.78% Race/ Ethnicity White 8,457 11,447 73.88% 7,684 11,189 68.67% 6,657 9,377 70.99% Black 657 1,102 59.62% 622 1,148 54.18% 667 1,098 60.75% Other 199 281 70.82% 194 301 64.45% 1,402 2,225 63.01% Hispanic 1,241 2,021 61.41% 1,316 2,426 54.25% 1,284 2,050 62.63% Age 10-14 s/n 20 s/n s/n 15 s/n s/n 9 s/n 15-17 144 328 43.90% 100 255 39.22% 97 233 41.63% 18-19 342 634 53.94% 281 630 44.60% 279 551 50.64% 20-24 1,527 2,577 59.25% 1,385 2,589 53.50% 1,492 2,669 55.90% 25-44 7,307 9,288 78.67% 6,797 9,241 73.55% 6,846 9,221 74.24% 45+ 7 9 77.78% 17 19 89.47% 11 18 61.11% Zones Central 2,848 3,893 73.16% 2,558 3,690 69.32% 2,400 3,707 64.74% East 2,401 2,974 80.73% 2,334 3,067 76.10% 2,214 2,848 77.74% Middletown City 900 1,365 65.93% 936 1,650 56.73% 1,338 2,133 62.73% Newburgh City 972 1,698 57.24% 907 1,770 51.24% 1,090 1,706 63.89% North 797 1047 76.12% 530 847 62.57% 407 599 67.95% Port Jervis City 295 470 62.77% 303 426 71.13% 328 508 64.57% West 1,119 1,409 79.42% 1,017 1,299 78.29% 950 1,200 79.17% *Births to Orange County residents recorded in NYC are not included in this analysis. ** Includes births registered in NYC. HV = Hudson Valley Rates are based on births with known risk factor information Data Source: NYS DOH Vital Statistics. Created by the School of Public Health, University at Albany, August, 2009 Exhibit 1A.48b 137

EARLY PRENATAL CARE (FIRST TRIMESTER) BIRTHS BY RACE AND ETHNICITY, ORANGE COUNTY, 1998-2006 80.00% 70.00% 60.00% 50.00% Rate 40.00% 30.00% 20.00% 10.00% 0.00% White Black Other Hispanic Race-Ethnicity (Maternal) 1998-2000 2001-2003 2004-2006 Rate per 100 live births within maternal race/ethnicity Data at county level does not include births to Orange County residents recorded in NYC. Data were obtained from New York State DOH Department of Vital Statistics. Created by the SUNY Albany School of Public Health, August 2009 Exhibit 1A.48c 138

EARLY PRENATAL CARE (FIRST TRIMESTER) BIRTHS BY ZONE, ORANGE COUNTY, 1998-2006 90.00% 80.00% 70.00% 60.00% Rate 50.00% 40.00% 30.00% 20.00% 10.00% 0.00% Central East Middletown City Newburgh City North Port Jervis City Health Planning Zone West 1998-2000 2001-2003 2004-2006 Rate per 100 live births within health planning zone Data at county level does not include births to Orange County residents recorded in NYC. Data were obtained from New York State DOH Department of Vital Statistics. Created by the SUNY Albany School of Public Health, August 2009 Exhibit 1A.48d 139

BIRTHS WITH EARLY (FIRST TRIMESTER) PRENATAL CARE PERCENTAGE PER 100 LIVE BIRTHS, ORANGE COUNTY AND UPSTATE NY, TEN YEAR TIME TREND 1997-2006 BIRTHS WITH EARLY (FIRST TRIMESTER) PRENATAL CARE PERCENTAGE PER 100 LIVE BIRTHS Year Single Year Orange County 3-Year Average Orange County Upstate New York 1997 72.4 79.2 1998 74.6 73.3 79.7 1999 73 72.9 79.1 2000 71.2 71 78.5 2001 68.8 69.9 77.7 2002 69.7 68.7 77.8 2003 67.7 69.6 77.9 2004 71.5 69.3 77.8 2005 68.7 69.6 77.9 2006 68.5 76.3 BIRTHS WITH EARLY (FIRST TRIMESTER) PRENATAL CARE PERCENTAGE PER 100 LIVE BIRTHS Births Early Prenatal Care Births* Percentage Region/County 2004 2005 2006 Total 2004-2006 Orange 3,399 3,072 3,125 9,596 13,791 69.6 Hudson Valley Region 18,171 18,256 17,495 53,922 73,474 73.4 New York State 175,196 174,851 174,252 524,299 699,756 74.9 Source: 2004-2006 NYSDOH Vital Statistics Data as of April, 2008 * Total births excludes births with unknown month prenatal care began. Exhibit 1A. 48e 140

BIRTHS WITH LATE (THIRD TRIMESTER) OR NO PRENATAL CARE BY RACE, ETHNICITY, AGE GROUP AND ZONE, ORANGE COUNTY, HUDSON VALLEY REGION, AND UPSTATE NY, 2004-2006 2004 2005 2006 Number Total Percent of Number Total Percent of Number Total Percent of Births Total Births Births Total Births Births Total Births Total Orange County* 189 4,383 4.31% 185 4,162 4.44% 179 4,156 4.31% HV Region** 1,065 29,166 3.65% 1,029 28,737 3.58% 1,115 28,890 3.86% Upstate NY** 4,227 103,351 4.09% 4,266 128,316 3.32% 5,013 129,752 3.86% Race/ Ethnicity White 111 3,337 3.33% 114 3,238 3.52% 104 2,802 3.71% Black 32 368 8.70% 26 354 7.34% 23 376 6.12% Other 46 678 6.78% 45 569 7.91% 52 978 5.32% Hispanic 45 673 6.69% 44 649 6.78% 41 728 5.63% Age 10-14 s/n s/n s/n s/n s/n s/n 0 s/n 0.00% 15-17 16 82 19.51% 13 87 14.94% 10 64 15.63% 18-19 16 190 8.42% 17 181 9.39% 18 180 10.00% 20-24 70 945 7.41% 48 870 5.52% 54 854 6.32% 25-44 87 3,159 2.75% 106 3,011 3.52% 97 3,051 3.18% 45+ s/n s/n s/n 0 9 0.00% 0 6 0.00% Zones Central 50 1,336 3.74% 36 1,232 2.92% 45 1,139 3.95% East 22 919 2.39% 30 955 3.14% 31 974 3.18% Middletown City 37 732 5.05% 41 696 5.89% 42 705 5.96% Newburgh City 58 669 8.67% 37 515 7.18% 29 522 5.56% North s/n 171 s/n 10 197 5.08% 7 231 3.03% Port Jervis City 8 172 4.65% 13 166 7.83% 12 170 7.06% West 10 384 2.60% 18 401 4.49% 13 415 3.13% *Births to Orange County residents recorded in NYC are not included in this analysis. ** Includes births registered in NYC. HV = Hudson Valley s/n = data are unreliable due to small number of cases Rates are based on births with known risk factor information. Data Source: NYS DOH Vital Statistics. Created by the School of Public Health, University at Albany, August, 2009 Exhibit 1A.49a 141

BIRTHS WITH LATE (THIRD TRIMESTER) OR NO PRENATAL CARE BY RACE, ETHNICITY, AGE GROUP AND ZONE, ORANGE COUNTY, HUDSON VALLEY REGION, AND UPSTATE NY,1998-2006 1998-2000 2001-2003 2004-2006 Number Total Percent of Number Total Percent of Number Total Percent of Births Total Births Births Total Births Births Total Births Total Orange County* 766 12,856 5.96% 680 12,749 5.33% 553 12,701 4.35% HV Region** 4,798 85,204 5.63% 4,194 85,423 4.91% 3,209 86,793 3.70% Upstate NY** 18,283 411,300 4.45% 18,557 400,511 4.63% 13,506 388,419 3.48% Race/ Ethnicity White 598 11,447 5.22% 527 11,189 4.71% 329 9,377 3.51% Black 142 1,102 12.89% 126 1,148 10.98% 81 1,098 7.38% Other 24 281 8.54% 25 301 8.31% 143 2,225 6.43% Hispanic 179 2,021 8.86% 202 2,426 8.33% 130 2,050 6.34% Age 10-14 6 20 30.00% s/n 15 s/n s/n 9 s/n 15-17 64 328 19.51% 42 255 16.47% 39 233 16.74% 18-19 81 634 12.78% 76 630 12.06% 51 551 9.26% 20-24 225 2,577 8.73% 208 2,589 8.03% 172 2,669 6.44% 25-44 389 9,288 4.19% 351 9,241 3.80% 290 9,221 3.14% 45+ s/n 9 s/n s/n 19 s/n 0 18 0.00% Zones Central 139 3,893 3.57% 132 3,690 3.58% 131 3,707 3.53% East 144 2,974 4.84% 119 3,067 3.88% 83 2,848 2.91% Middletown City 102 1,365 7.47% 117 1,650 7.09% 120 2,133 5.63% Newburgh City 215 1,698 12.66% 200 1,770 11.30% 124 1,706 7.27% North 61 1047 5.83% 41 847 4.84% 21 599 3.51% Port Jervis City 57 470 12.13% 27 426 6.34% 33 508 6.50% West 48 1,409 3.41% 44 1,299 3.39% 41 1,200 3.42% *Births to Orange County residents recorded in NYC are not included in this analysis. ** Includes births registered in NYC. HV = Hudson Valley s/n = data are unreliable due to small number of cases Rates are based on births with known risk factor information Data Source: NYS DOH Vital Statistics. Created by the School of Public Health, University at Albany, August, 2009 Exhibit 1A.49b 142

BIRTHS WITH LATE (THIRD TRIMESTER) OR NO PRENATAL CARE BY MATERNAL RACE, ETHNICITY, ORANGE COUNTY, 2004-2006 14.00% 12.00% 10.00% Rate 8.00% 6.00% 4.00% 2.00% 0.00% White Black Other Hispanic Race-Ethnicity (Maternal) 1998-2000 2001-2003 2004-2006 Rate per 100 live births within race/ethnicity Births to Orange County residents recorded in NYC are not included in this analysis. Rates are based on births with known risk factor information Data Source: NYS DOH Vital Statistics. Created by the School of Public Health, University at Albany, August, 2009 Exhibit 1A.49c 143

BIRTHS WITH LATE (THIRD TRIMESTER) OR NO PRENATAL CARE BY ZONE, ORANGE COUNTY, 2004-2006 14.00% 12.00% 10.00% Rate 8.00% 6.00% 4.00% 2.00% 0.00% Central East Middletown City Newburgh City North Port Jervis City Health Planning Zones West 1998-2000 2001-2003 2004-2006 Rate per 100 live births within health planning zone Births to Orange County residents recorded in NYC are not included in this analysis. Rates are based on births with known risk factor information Data Source: NYS DOH Vital Statistics. Created by the School of Public Health, University at Albany, August, 2009 Exhibit 1A.49d 144

BIRTHS WITH LATE (LAST TRIMESTER, NO CARE) PRENATAL CARE PERCENTAGE PER 100 LIVE BIRTHS, ORANGE COUNTY AND UPSTATE NY, TEN YEAR TIME TREND 1997-2006 BIRTHS WITH LATE (LAST TRIMESTER, NO CARE) PRENATAL CARE PERCENTAGE PER 100 LIVE BIRTHS Year Single Year Orange County 3-Year Average Orange County Upstate New York 1997 5.6 4.4 1998 5.3 5.6 4.5 1999 5.8 5.9 4.8 2000 6.5 5.9 4.8 2001 5.3 5.5 5.2 2002 4.8 5 4.9 2003 5 4.6 4.9 2004 4.1 4.4 3.6 2005 4.2 4.4 3.6 2006 4.8 4.2 BIRTHS WITH LATE (LAST TRIMESTER, NO CARE) PRENATAL CARE PERCENTAGE PER 100 LIVE BIRTHS Births with Late Prenatal Births* Percentrage Region/County 2004 2005 2006 Total 2004-2006 Orange 196 187 221 604 13,791 4.4 Hudson Valley Region 1,065 1,032 1,115 3,212 73,474 4.4 New York State Total 11,608 11,368 12,060 35,036 699,756 5 Source: 2004-2006 NYSDOH Vital Statistics Data as of April, 2008 * Total births excludes births with unknown month prenatal care began. Exhibit 1A.49e 145

EARLY GESTATIONAL AGE BIRTHS (<37 WEEKS GESTATION), BY RACE, ETHNICITY, AGE, AND ZONE ORANGE COUNTY, 1998-2006 2004 2005 2006 Number Total Percent of Number Total Percent of Number Total Percent of Births Total Births Births Total Births Births Total Births Total Orange County 518 4,825 10.74% 525 4,847 10.83% 458 5,056 9.06% HV Region** n/a 29,166 n/a n/a 28,737 n/a n/a 28,890 n/a Upstate NY** n/a 130,351 n/a na/ 128,316 n/a n/a 129,752 n/a Race/Ethnicity White 351 3,666 9.57% 404 3,701 10.92% 297 3,462 8.58% Black 57 413 13.80% 70 446 15.70% 48 452 10.62% Other 109 743 14.67% 51 697 7.32% 113 1139 9.92% Hispanic 88 714 12.32% 75 747 10.04% 83 857 9.68% Age 10-14 s/n 6 s/n s/n s/n s/n s/n s/n s/n 15-17 7 85 8.24% 9 104 8.65% 9 84 10.71% 18-19 39 212 18.40% 27 207 13.04% 14 212 6.60% 20-24 97 1014 9.57% 106 1033 10.26% 88 1045 8.42% 25-44 371 3,501 10.60% 378 3,489 10.83% 344 3,703 9.29% 45+ s/n 6 s/n s/n 9 s/n s/n 8 s/n Zones Central 134 1,476 9.08% 140 1,502 9.32% 120 1,592 7.54% East 103 1,061 9.71% 105 1,077 9.75% 109 1120 9.73% Middletown 89 764 11.65% 107 755 14.17% 70 740 9.46% Newburgh City 103 735 14.01% 66 664 9.94% 65 691 9.41% North 21 180 11.67% 27 213 12.68% 19 248 7.66% Port Jervis City 20 177 11.30% 20 185 10.81% 31 191 16.23% West 48 432 11.11% 60 451 13.30% 44 474 9.28% This analysis does not contain births registered to Orange County residents recorded in NYC. n/a=data is not available for these years for these regions. s/n = data are unreliable due to small number of cases HV = Hudson Valley Rates are based on births with known risk factor information Data Source: NYS DOH Vital Statistics. Created by the School of Public Health, University at Albany, August, 2009 Exhibit 1A.50a 146

EARLY GESTATIONAL AGE BIRTHS (<37 WEEKS GESTATION) BY RACE, ETHNICITY, AGE AND ZONE ORANGE COUNTY, 1998-2006 1998-2000 2001-2003 2004-2006 Number Total Percent of Number Total Percent of Number Total Percent of Births Total Births Births Total Births Births Total Births Total Orange 1,366 13,478 10.14% 1,303 13,283 9.81% 1,501 14,728 10.19% HV Region 9,177 89,852 10.21% 9,180 88,373 10.39% n/a 86,793 n/a Upstate NY 41,964 411,300 10.20% 41,334 400,511 10.32% n/a 388,419 n/a Race/Ethnicity White 1,124 12,044 9.33% 1,104 11,685 9.45% 1,052 10,829 9.71% Black 207 1,218 17.00% 162 1,167 13.88% 175 1,311 13.35% Other 32 296 10.81% 25 314 7.96% 273 2579 10.59% Hispanic 245 2,041 12.00% 282 2,454 11.49% 246 2,318 10.61% Age 10-14 s/n 16 s/n s/n 16 s/n s/n 13 s/n 15-17 55 326 16.87% 29 259 11.20% 25 273 9.16% 18-19 90 652 13.80% 69 631 10.94% 80 631 12.68% 20-24 247 2,682 9.21% 264 2,640 10.00% 291 3,092 9.41% 25-44 969 9,789 9.90% 935 9,717 9.62% 1093 10,693 10.22% 45+ s/n 13 s/n s/n 20 s/n 9 23 39.13% Zones Central 327 4,255 7.69% 302 3,930 7.68% 394 4,570 8.62% East 319 3,045 10.48% 300 3,146 9.54% 317 3,258 9.73% Middletown 180 1,395 12.90% 181 1,677 10.79% 266 2,259 11.78% Newburgh 235 1,678 14.00% 259 1,776 14.58% 234 2,090 11.20% North 100 1,060 9.43% 92 873 10.54% 67 641 10.45% Port Jervis 59 484 12.19% 45 444 10.14% 71 553 12.84% West 146 1,561 9.35% 124 1,437 8.63% 152 1,357 11.20% This analysis does not contain births registered to Orange County residents recorded in NYC. n/a= Data on preterm births for these regions are not available at this time. s/n = data are unreliable due to small number of cases HV = Hudson Valley Rates are based on births with known risk factor information Data Source: NYS DOH Vital Statistics. Created by the School of Public Health, University at Albany, August, 2009 Exhibit 1A.50b 147

EARLY GESTATIONAL AGE BIRTHS (<37 WEEKS) BY MATERNAL RACE AND ETHNICITY, ORANGE COUNTY, 1998-2006 18.00% 16.00% 14.00% 12.00% Rate 10.00% 8.00% 6.00% 4.00% 2.00% 0.00% White Black Other Hispanic Race Ethnicity (Maternal) 1998-2000 2001-2003 2004-2006 Rate per 100 live births by maternal race/ethnicity Data at county level does not include births to Orange County residents recorded in NYC. Data were obtained from New York State DOH Department of Vital Statistics. Created by the SUNY Albany School of Public Health, August 2009 Exhibit 1A.50c 148

EARLY GESTATIONAL AGE BIRTHS (<37 WEEKS) BY ZONE ORANGE COUNTY, 1998-2006 16.00% 14.00% 12.00% 10.00% Rate 8.00% 6.00% 4.00% 2.00% 0.00% Central East Middletown City Newburgh City North Health Planning Zones Port Jervis City West 1998-2000 2001-2003 2004-2006 Rate per 100 live births within health planning zone Data at county level does not include births to Orange County residents recorded in NYC. Data were obtained from New York State DOH Department of Vital Statistics. Created by the SUNY Albany School of Public Health, August 2009 Exhibit 1A.50d 149

SHORT GESTATION BIRTHS (<37 WEEKS GESTATION) PER 100 LIVE BIRTHS, ORANGE COUNTY AND UPSTATE NY, TEN YEAR TIME TREND, 1997-2006 SHORT GESTATION (<37 WEEKS) PER 100 LIVE BIRTHS Year Single Year Orange County 3-Year Average Orange County Upstate New York 1997 10.6 10 1998 10 10.1 10 1999 9.6 10.3 10.3 2000 11.2 10.5 11.3 2001 10.7 10.5 10.7 2002 9.6 10 10.8 2003 9.6 10.2 10.8 2004 11.5 11 11.4 2005 11.9 11.3 11.8 2006 10.6 12 SHORT GESTATION (<37 WEEKS) - PER 100 LIVE BIRTHS Births with Short Gestation (<37 weeks) Births* Percentrage Region/County 2004 2005 2006 Total 2004-2006 Orange 564 562 504 1,630 14,426 11.3 Hudson Valley Region 2,949 3,134 3,025 9,108 79,536 11.5 New York State 29,100 29,343 30,030 88,473 717,395 12.3 Source: 2004-2006 NYSDOH Vital Statistics Data as of April, 2008 * Total births excludes births with unknown gestation Exhibit 1A.50e 150

LOW BIRTHWEIGHT INFANTS (<2500 GRAMS), BY RACE, ETHNICITY, AGE AND ZONE, ORANGE COUNTY, 2004-2006 2004 2005 2006 Number Total Percent of Number Total Percent of Number Total Percent of Births Total Births Births Total Births Births Total Births Total Orange County* 344 4,824 7.13% 365 4,846 7.53% 327 5,055 6.47% HV Region** 2,178 29,166 7.47% 2,223 28,737 7.74% 2,229 28,890 7.72% Upstate NY** 9,873 130,351 7.57% 9,916 128,316 7.73% 10,238 129,752 7.89% Race/Ethnicity White 228 3,665 6.22% 239 3,701 6.46% 186 3,462 5.37% Black 51 413 12.35% 72 446 16.14% 55 452 12.17% Other 63 743 8.48% 54 697 7.75% 86 1,138 7.56% Hispanic 43 714 6.02% 47 747 6.29% 58 856 6.78% Age 10-14 0 6 0.00% s/n s/n s/n s/n s/n s/n 15-17 10 85 11.76% 11 104 10.58% 8 84 9.52% 18-19 23 211 10.90% 19 207 9.18% 15 212 7.08% 20-24 58 1,014 5.72% 77 1033 7.45% 60 1,044 5.75% 25-44 250 3,501 7.14% 254 3,489 7.28% 238 3,703 6.43% 45+ s/n 6 s/n s/n 9 s/n s/n 8 s/n Zones Central 76 1,476 5.15% 74 1,502 4.93% 88 1,592 5.53% East 76 1,061 7.16% 88 1,077 8.17% 72 1,120 6.43% Middletown City 73 764 9.55% 69 755 9.14% 57 740 7.70% Newburgh City 62 735 8.44% 67 663 10.11% 54 690 7.83% North 18 180 10.00% 13 213 6.10% 11 248 4.44% Port Jervis City 9 176 5.11% 13 185 7.03% 13 191 6.81% West 30 432 6.94% 41 451 9.09% 32 474 6.75% *Births to Orange County residents recorded in NYC are not incorporated into this analysis. ** Births recorded in NYC are included in this analysis. s/n = Data are unreliable due to small number of cases HV = Hudson Valley Rates are based on births with known risk factor information Data Source: NYS DOH Vital Statistics. Created by the School of Public Health, University at Albany, August, 2009 Exhibit 1A.51a 151

LOW BIRTHWEIGHT INFANTS (<2500 GRAMS), BY RACE, ETHNICITY, AGE AND ZONE ORANGE COUNTY, 1998-2006 1998-2000 2001-2003 2004-2006 Number Total Percent of Number Total Percent of Number Total Percent of Births Total Births Births Total Births Births Total Births Total Orange County* 887 14,180 6.26% 829 13,852 5.98% 1036 14,725 7.04% HV Region** 6,176 89,852 6.87% 6,069 88,373 6.87% 6,630 86,793 7.64% Upstate NY** 29,589 411,300 7.19% 29,137 400,511 7.27% 30,027 388,419 7.73% Race/Ethnicity White 673 12,619 5.33% 650 12,174 5.34% 653 10,828 6.03% Black 185 1,218 15.19% 142 1,233 11.52% 178 1,311 13.58% Other 27 313 8.63% 25 328 7.62% 203 2578 7.87% Hispanic 137 2,165 6.33% 153 2,544 6.01% 148 2,317 6.39% Age 10-14 s/n 20 s/n s/n 19 s/n s/n 13 s/n 15-17 34 360 9.44% 24 273 8.79% 29 273 10.62% 18-19 51 712 7.16% 52 671 7.75% 57 630 9.05% 20-24 194 2,879 6.74% 167 2,783 6.00% 195 3,091 6.31% 25-44 603 10,195 5.91% 582 10,067 5.78% 742 10,693 6.94% 45+ 0 14 0.00% s/n 20 s/n 9 23 39.13% Zones Central 182 4,470 4.07% 178 4,135 4.30% 238 4,570 5.21% East 200 3,176 6.30% 194 3,265 5.94% 236 3,258 7.24% Middletown City 109 1,464 7.45% 118 1,732 6.81% 199 2,259 8.81% Newburgh City 179 1,871 9.57% 168 1,889 8.89% 183 2,088 8.76% North 67 1094 6.12% 57 900 6.33% 42 641 6.55% Port Jervis City 43 501 8.58% 29 446 6.50% 35 552 6.34% West 107 1,604 6.67% 85 1,485 5.72% 103 1,357 7.59% *Analysis does not include births to Orange County residents recorded in NYC. **Analysis includes births recorded in NYC. s/n = Data are unreliable due to small number of cases HV = Hudson Valley Rates are based on births with known risk factor information Data Source: NYS DOH Vital Statistics. Created by the School of Public Health, University at Albany, August, 2009 Exhibit 1A.51b 152

LOW BIRTHWEIGHT (<2500gms) INFANTS BY MATERNAL RACE AND ETHNICITY ORANGE COUNTY, 1998-2006 16.00% 14.00% 12.00% 10.00% Rate 8.00% 6.00% 4.00% 2.00% 0.00% White Black Other Hispanic Race-Ethnicity (Maternal) 1998-2000 2001-2003 2004-2006 Rate per 100 live births by maternal race/ethnicity Data at county level does not include births to Orange County residents recorded in NYC. Data were obtained from New York State DOH Department of Vital Statistics. Created by the SUNY Albany School of Public Health, August 2009 Exhibit 1A.51c 153

LOW BIRTHWEIGHT INFANTS (<2500 gms) BY ZONE, ORANGE COUNTY, 1998-2006 12.00% 10.00% 8.00% Rate 6.00% 4.00% 2.00% 0.00% Central East Middletown City Newburgh City North Port Jervis City West Health Planning Zone 1998-2000 2001-2003 2004-2006 Rate per 100 live births within health planning zone Data at county level does not include births to Orange County residents recorded in NYC. Data were obtained from New York State DOH Department of Vital Statistics. Created by the SUNY Albany School of Public Health, August 2009 Exhibit 1A.51d 154

LOW BIRTHWEIGHT BIRTHS (<2500 GRAMS) PERCENTAGE BIRTHS PER 100 LIVE BIRTHS, ORANGE COUNTY AND UPSTATE NY, TEN YEAR TIME TREND, 1997-2006 LOW BIRTHWEIGHT (<2500 grams) PER 100 LIVE BIRTHS Year Single Year Orange County 3-Year Average Orange County Upstate New York 1997 7.1 7 1998 6.5 6.5 7 1999 5.8 6.3 7.2 2000 6.6 6.1 7.3 2001 6 6.2 7 2002 6.1 6.2 7.5 2003 6.5 6.5 7.4 2004 7 7.1 7.6 2005 7.7 7.1 7.7 2006 6.7 7.9 LOW BIRTHWEIGHT (<2500 grams) PER 100 LIVE BIRTHS Births with Low Birthweight (<2500g) Births* Percentage Region/County 2004 2005 2006 Total 2004-2006 Orange 366 396 365 1,127 15,800 7.1 Hudson Valley Region 2,178 2,221 2,229 6,628 86,662 7.6 New York State 20,361 20,368 20,759 61,488 743,093 8.3 Source: 2004-2006 NYSDOH Vital Statistics Data as of April, 2008 * Total births excludes births with unknown birthweight. Exhibit 1A. 51e 155

PREGNANCY RATES, FEMALES AGE (15-44), ORANGE COUNTY AND UPSTATE, TEN YEAR TIME TREND, 1997-2006 PREGNANCY RATES FEMALES (AGE 15-44) PER 1,000 FEMALES Year Single Year Orange 3-Year Average Upstate New County Orange County York 1997 96 80 1998 92.7 93.8 78.5 1999 92.6 92.7 77.8 2000 92.8 92.7 78.3 2001 92.9 91.9 76.7 2002 89.9 89.6 76.3 2003 86.2 87.5 76 2004 86.6 86.6 75.2 2005 87.1 87.8 76 2006 89.8 78 PREGNANCY RATES FEMALES (AGE 15-44) PER 1,000 FEMALES Pregnancies Age (15-44) Population Rate Region/County 2004 2005 2006 Total 2004-2006 Orange 6,880 6,829 7,203 20,912 78,447 88.9 Hudson Valley Region 36,896 38,290 38,855 114,041 452,930 83.9 New York State 387,493 381,719 388,086 1,157,298 4,084,946 94.4 Source: 2004-2006 NYSDOH Vital Statistics Data as of March, 2008 Exhibit 1A. 52 156

BIRTH RATES BY MATERNAL RACE/ETHNICITY, AGE, AND ZONE, PER 1,000 FEMALES AGES 15-44 ORANGE COUNTY HUDSON VALLEY REGION AND UPSTATE NY, 1998-200 Number of Births 1998-2000 2001-2003 2004-2006 Female Number of Female Number of Female Rate Rate Rate Population Births Population Births Population Orange County 14,191 206,889 68.6 13,864 219,207 63.2 14,728 228,436 64.5 Total HV Region 84,021 1,362,631 61.7 88,373 1,369,701 64.5 83,892 1,359,862 61.7 Upstate NY 411,280 6,930,504 59.3 400,511 6,834,586 58.6 388,419 6,701,068 58.0 Race/ Ethnicity** White 12,622 173,958 72.6 12,177 173,958 70.0 10,829 193,171 56.1 Black 1,220 27,453 44.4 1,233 18,633 66.2 1,311 19,204 68.3 Other 313 15,082 20.8 328 15,082 21.7 2,579 16,242 158.8 Hispanic 2,166 27,453 78.9 2,545 28,803 88.4 2,318 29,596 78.3 Age <15 20 39,244 0.5 19 42,795 0.4 13 43,877 0.3 15-24 3,958 58,765 67.4 3,728 62,311 59.8 3,996 64,973 61.5 25-34 7,686 63,153 121.7 7,484 66,845 112.0 7,811 69,602 112.2 35-44 2,513 84,970 29.6 2,594 90,060 28.8 2,882 93,862 30.7 45+ 14 68,466 0.2 20 73,604 0.3 23 75,752 0.3 Zones Central 4,471 52,292 85.5 4,139 57,765 71.7 4,570 61,879 73.9 East 3,179 59,750 53.2 3,272 62,001 52.8 3,258 64,407 50.6 Middletown City 1,466 15,760 93.0 1,732 16,389 105.7 2,259 16,548 136.5 Newburgh City 1,875 19,362 96.8 1,889 20,274 93.2 2,090 20,232 103.3 North 1,094 20,589 53.1 900 21,475 41.9 641 22,654 28.3 Port Jervis City 501 5,495 91.2 447 5,612 79.7 553 5,679 97.4 West 1,605 33,641 47.7 1,485 35,691 41.6 1,357 37,037 36.6 HV = Hudson Valley Populations used in calculating rates are from the US Census 1990 & 2000 population with bridged race categories and interpolated for intervening years from the NCHS. Data Source: NYS DOH Vital Statistics. Vital records for events registered in New York City are not yet incorporated into this analysis. Created by the School of Public Health, University at Albany, August, 2009 ** Rates for other race in 2004-2006 may not be representative of what is occurring in the population due to changes in the manner that maternal race/ethnicity is quantified on the birth certificate and the interpolation of bridged race estimates in the population denominator. Exhibit 1A.53a 157

BIRTH RATE FEMALES AGES (15-44), ORANGE COUNTY AND UPSTATE NY, TEN YEAR TIME TREND, 1997-2006 BIRTH RATE AGES (15-44) PER 1,000 FEMALES Year Single Year Orange County 3-Year Average Orange County Upstate New York 1997 68.9 59.1 1998 67.2 68.1 59.3 1999 68.2 67.8 58.9 2000 68 67.7 59.7 2001 67.1 67.2 58.4 2002 66.6 66.6 57.8 2003 66.2 66.3 58.3 2004 66.3 66.1 57.5 2005 65.8 66.6 57.3 2006 67.8 58 BIRTH RATE AGES (15-44) PER 1,000 FEMALES Births Females Age (15-44) Population Rate Region/County 2004 2005 2006 Total 2004-2006 Orange 5,206 5,165 5,433 15,804 78,447 67.2 Hudson Valley Region 29,166 28,715 28,890 86,771 452,930 63.9 New York State 249,000 245,377 249,182 743,559 4,084,946 60.7 Source: 2004-2006 NYSDOH Vital Statistics Data as of April, 2008 Exhibit 1A. 53b 158

MATERNAL MORTALITY - RATE PER 100,000 LIVE BIRTHS, ORANGE COUNTY, HUDSON VALLEY REGION, AND NYS, 2004-2006 Maternal Deaths HP 2010 Targets: 3.3/100,000 Live Births Births Rate REGION/COUNTY 2004 2005 2006 TOTAL 2004-2006 Orange 1 0 1 2 15,804 12.7 Hudson Valley Region 5 2 2 9 86,771 10.4 New York State 51 37 48 136 743,559 18.3 Source: 2004-2006 NYSDOH Vital Statistics Data as of April, 2008 Exhibit 1.A 54 159

INFANT MORTALITY RATES PER 1,000 BY RACE AND ETHNICITY, ORANGE COUNTY, 2004-2006 2004 2005 2006 Number Total Rate Per 1000 Number Total Rate Per 1000 Number Total Rate Per 1000 Births Population Births Population Births Population Total Orange 33 4,825 6.84 25 4,847 5.16 15 5,056 2.97 HV Region 155 29,166 5.31 160 28,737 5.57 115 28,890 3.98 Upstate NY 775 130,351 5.95 749 128,316 5.84 699 129,752 5.39 Race White* 21 3,666 5.73 13 3,701 3.51 10 3,462 2.89 Black* s/n 413 s/n 9 446 20.18 s/n 452 s/n Other* 7 743 9.42 s/n 697 s/n s/n 1139 s/n Hispanic* s/n 714 s/n s/n 747 s/n s/n 857 s/n INFANT MORTALITY RATES PER 1,000 BY RACE AND ETHNICITY AND ZONE, ORANGE COUNTY, 1998-2006 1998-2000 2001-2003 2004-2006 Number Total Rate Per 1000 Number Total Rate Per 1000 Number Total Rate Per 1000 Births Population Births Population Births Population Total Orange 48 14,191 3.38 66 13,864 4.76 73 14,728 4.96 HV Region 448 89,852 4.99 392 88,373 4.44 430 86,793 4.95 Upstate NY 2,462 411,300 5.99 2,372 400,511 5.92 2,223 388,419 5.72 Race White* 39 12,622 3.09 53 12,177 4.35 44 10,829 4.06 Black* 7 1,220 5.74 12 1,233 9.73 16 1,311 12.20 Other* s/n 313 s/n s/n 328 s/n 13 2,579 5.04 Hispanic* 9 2,166 4.16 13 2,545 5.11 11 2,318 4.75 Zones Central 9 4,471 2.01 15 4,139 3.62 18 4,570 3.94 East 11 3,179 3.46 19 3,272 5.81 9 3,258 2.76 Middle 9 1,466 6.14 12 1,732 6.93 21 2,259 9.30 Newburgh 7 1,875 3.73 14 1,889 7.41 15 2,090 7.18 North s/n 1,094 s/n s/n 900 s/n s/n 641 s/n Port Jervis s/n 501 s/n s/n 447 s/n s/n 553 s/n West s/n 1,605 s/n s/n 1,485 s/n 7 1,357 5.16 *Births to Orange County residents recorded in NYC are not included in this analysis. s/n= data unreliable due to small number of cases Infant Mortality=infant deaths under 1 year of age. HV = Hudson Valley Rates are based on births with known risk factor information. Data Source: NYS DOH Vital Statistics. Created by the School of Public Health, University at Albany, August, 2009 Exhibit 1A.55 160

NEONATAL MORTALITY RATES PER 1,000 BY RACE AND ETHNICITY, ORANGE COUNTY, 2004-2006 2004 2005 2006 Number Total Rate Per 1000 Number Total Rate Per 1000 Number Total Rate Per 1000 Births Population Births Population Births Population Total Orange 24 4,825 4.97 18 4,847 3.71 9 5,056 1.78 HV Region 116 29,166 3.98 111 28,737 3.86 75 28,890 2.60 Upstate NY 568 130,351 4.36 551 128,316 4.29 485 129,752 3.74 Race White* 16 3,666 4.36 11 3,701 2.97 7 3,462 2.02 Black* s/n 413 s/n s/n 446 s/n 0 452 0.00 Other* s/n 743 s/n s/n 697 s/n s/n 1139 s/n Hispanic* s/n 714 s/n s/n 747 s/n s/n 857 s/n NEONATAL MORTALITY RATES PER 1,000 BY RACE AND ETHNICITY, ORANGE COUNTY, 1998-2006 1998-2000 2001-2003 2004-2006 Number Total Rate Per 1000 Number Total Rate Per 1000 Number Total Rate Per 1000 Births Population Births Population Births Population Total Orange 31 14,191 2.18 42 13,864 3.03 51 14,728 3.46 HV Region 308 89,852 3.43 263 88,373 2.98 302 86,793 3.48 Upstate NY 1,755 411,300 4.27 1,703 400,511 4.25 1,604 388,419 4.13 Race White* 26 12,622 2.06 33 12,177 2.71 34 10,829 3.14 Black* s/n 1,220 s/n 8 1,233 6.49 8 1,311 6.10 Other* 0 313 0.00 s/n 328 s/n 9 2579 3.49 Hispanic* 6 2,166 2.77 8 2,545 3.14 9 2,318 3.88 *Births to Orange County residents recorded in NYC are not included in this analysis. Neonatal Mortality=infant deaths that occur between 0 and 27 days old s/n= data are unreliable due to small number of cases HV = Hudson Valley Rates are based on births with known risk factor information. Data Source: NYS DOH Vital Statistics. Created by the School of Public Health, University at Albany, August, 2009 Exhibit 1A.56 161

POST-NEONATAL MORTALITY RATES PER 1,000 BY RACE AND ETHNICITY, ORANGE COUNTY, 2004-2006 2004 2005 2006 Number Total Rate Per 1000 Number Total Rate Per 1000 Number Total Rate Per 1000 Births Population Births Population Births Population Total Orange 9 4,825 1.87 7 4,847 1.44 6 5,056 1.19 HV Region 39 29,166 1.34 49 28,737 1.71 40 28,890 1.38 Upstate NY 207 130,351 1.59 198 128,316 1.54 214 129,752 1.65 Race White* s/n 3,666 s/n s/n 3,701 s/n s/n 3,462 s/n Black* s/n 413 s/n s/n 446 s/n s/n 452 s/n Other* s/n 743 s/n s/n 697 s/n s/n 1139 s/n Hispanic* s/n 714 s/n s/n 747 s/n 0 857 0.00 POST-NEONATAL MORTALITY RATES PER 1,000 BY RACE AND ETHNICITY, ORANGE COUNTY, 1998-2006 1998-2000 2001-2003 2004-2006 Number Total Rate Per 1000 Number Total Rate Per 1000 Number Total Rate Per 1000 Births Population Births Population Births Population Total Orange 17 14,191 1.20 24 13,864 1.73 22 14,728 1.49 HV Region 140 89,852 1.56 129 88,373 1.46 128 86,793 1.47 Upstate NY 707 411,300 1.72 669 400,511 1.67 619 388,419 1.59 Race White* 13 12,622 1.03 20 12,177 1.64 10 10,829 0.92 Black* s/n 1,220 s/n s/n 1,233 s/n 8 1,311 6.10 Other* s/n 313 s/n 0 328 0.00 s/n 2579 s/n Hispanic* s/n 2,166 s/n s/n 2,545 s/n s/n 2,318 s/n *Births to Orange County residents recorded in NYC are not included in this analysis. Post-neonatal Mortality=infant deaths that occur between 28 days old and less than 1 year old. s/n= data are unreliable due to small number of cases HV = Hudson Valley Rates are based on births with known risk factor information. Data Source: NYS DOH Vital Statistics. Created by the School of Public Health, University at Albany, August, 2009 Exhibit 1A.57 162

INFANT MORTALITY RATES, ORANGE COUNTY AND UPSTATE NY, TEN YEAR TIME TRENDS 1997-2006 INFANT MORTALITY RATE PER 1,000 LIVE BIRTHS Year Single Year Orange County 3-Year Average Orange County Upstate New York 1997 6.4 6.5 1998 5.9 6.3 5.9 1999 6.6 5.9 6 2000 5.1 5.4 6.2 2001 4.7 4.8 5.9 2002 4.8 5.2 6 2003 6.2 5.9 5.8 2004 6.5 6.3 6 2005 6 5.3 5.9 2006 3.5 5.5 INFANT MORTALITY RATE PER 1,000 LIVE BIRTHS Deaths <1 Year Births Rate Region/County 2004 2005 2006 Total 2004-2006 Orange 34 31 19 84 15,804 5.3 Hudson Valley Region 156 162 112 430 86,771 5 New York State 1,502 1,412 1390 1,390 4,304 743,559 58 5.8 Source: 2004-2006 NYSDOH Vital Statistics Data as of March, 2008 Exhibit 1A. 58 163

NEONATAL MORTALITY RATES, ORANGE COUNTY AND UPSTATE NEW YORK, TEN YEAR TIME TRENDS, 1997-2006 NEONATAL MORTALITY RATES PER 1,00 LIVE BIRTHS Year Single Year Orange County 3-Year Average Orange County Upstate New York 1997 4.3 4.6 1998 3.8 4.1 4.2 1999 4.1 3.9 4.1 2000 3.7 3.4 4.5 2001 2.4 3.3 4 2002 3.8 3.2 4.5 2003 3.5 4.2 4.2 2004 5.4 4.3 4.4 2005 4.1 3.9 4.3 2006 2.2 3.8 NEONATAL MORTALITY RATES PER 1,00 LIVE BIRTHS Deaths <28 Days Births Rate Region/County 2004 2005 2006 Total 2004-2006 Orange 28 21 12 61 15,804 3.9 Hudson Valley Region 116 111 73 300 86,771 3.5 New York State 1,058 982 935 2,975 743,559 4 Source: 2004-2006 NYSDOH Vital Statistics Data as of March, 2008 Exhibit 1A. 59 164

POST NEONATAL MORTALITY RATES, ORANGE COUNTY AND UPSTATE NEW YORK, TEN YEAR TIME TRENDS, 1997-2006 POSTNEONATAL MORTALITY RATE PER 1,000 LIVE BIRTHS Year Single Year Orange County 3-Year Average Orange County Upstate New York 1997 2.1 1.9 1998 2.1 2.2 1.7 1999 2.5 2 1.9 2000 1.4 2 1.7 2001 2.2 1.5 1.9 2002 1 2 1.6 2003 2.7 1.6 1.7 2004 1.2 1.9 1.6 2005 1.9 1.5 1.6 2006 1.3 1.7 POSTNEONATAL MORTALITY RATE PER 1,000 LIVE BIRTHS Deaths <28 Days - <1 Year Births Rate Region/County 2004 2005 2006 Total 2004-2006 Orange 6 10 7 23 15,804 1.5 Hudson Valley Region 40 51 39 130 86,771 1.5 New York State 444 430 455 1,329 743,559 1.8 Source: 2004-2006 NYSDOH Vital Statistics Data as of March, 2008 Exhibit 1A. 60 165

VERY LOW BIRTHWEIGHT BIRTHS (<1500 GRAMS) INFANTS, ORANGE COUNTY AND UPSTATE NEW YORK, TEN YEAR TIME TRENDS, 1997-2006 VERY LOW BIRTHWEIGHT (<1500 GRAMS) BIRTH PERCENT OF LIVE BIRTHS Single Year 3-Year Average Upstate New Year Orange County Orange County York 1997 1.4 1.4 1998 1.4 1.3 1.3 1999 1.2 1.3 1.4 2000 1.2 1.2 1.5 2001 12 1.2 12 1.2 14 1.4 2002 1.2 1.2 1.4 2003 1.2 1.2 1.4 2004 1.2 1.3 1.5 2005 1.4 1.2 1.4 2006 1 1.5 VERY LOW BIRTHWEIGHT (<1500 GRAMS) BIRTH PERCENT OF LIVE BIRTHS Births <1500 Grams Births Percentage Region/County 2004 2005 2006 Total 2004-2006 Orange 63 72 52 187 15,800 1.2 Hudson Valley Region 415 398 393 1,206 86,662 1.4 New York State 3,964 3,766 3,850 11,580 743,093 1.6 Source: 2004-20062006 NYSDOH Vital l Statistics ti ti Data as of March, 2008 Exhibit 1A. 61 166

NEWBORN DRUG-RELATED DISCHARGES, ORANGE COUNTY AND UPSTATE NEW YORK, TEN YEAR TIME TRENDS, 1997-2006 NEWBORN DRUG-RELATED DISCHARGE RATE PER 10,000 NEWBORNS Year Single Year Orange County 3-Year Average Orange County Upstate New York 1997 18.3 60.7 1998 21.5 18 51.7 1999 14.2 19.4 52.9 2000 22.2 18.9 48.4 2001 20.1 26.5 50.9 2002 36.7 27.5 53.6 2003 25.5 26.7 58.3 2004 18.4 23 56.2 2005 25.1 23.3 56 2006 26.4 61.4 NEWBORN DRUG-RELATED DISCHARGE RATE PER 10,000 NEWBORNS Region/County 2004 2005 2006 Total 2004-2006 Orange 9 12 13 34 14,592 23.3 Hudson Valley Region 89 74 87 250 80,269 31.1 New York State 1,448 1,322 1,415 4,185 722,338 57.9 Discharge rate per 10,000 000 newborn discharges Source: 2004-2006 SPARCS Data as of March, 2008 Exhibit 1A. 62 167

COMPARISON OF DOMESTIC VIOLENCE REPORTING AND ARREST RATES IN NEW YORK STATE: ANALYSIS OF THE 1997 AND 2000 DOMESTIC INCIDENT STATISTICAL DATABASES County Incidence Rate Per 10,000 County 1997 with State Police 1997 2000 1997 with State Police 1997 2000 Dutchess 107 94 129 74 65 81 Orange 90 91 119 74 74 91 Putnam 53 50 73 44 41 56 Rockland 103 103 99 64 64 58 Sullivan 76 45 59 61 36 Ulster 87 59 60 68 46 46 Westchester 85 82 84 58 56 52 Range 27-252 28-257 23-284 18-165 23-188 18-220 County Average 105 101 114 77 74 79 Standard Deviation 51 59 62 33 40 40 State Average 137 133 144 88 73 85 by Adriana Fernandez-Lanier, PhD, Deborah J. Chard-Wierschem, PhD, and Donna Hall, PhD Office of Justice Systems Analysis Criminal Incidence Per 10,000 Exhibit 1A. 63 168

HOMICIDE MORTALITY ORANGE COUNTY, HUDSON VALLEY REGION AND NYS, 2004-2006 PER 100,000 RESIDENTS Deaths Population Crude Adjusted Region/County 2004 2005 2006 Total 2005 Rate Rate Orange 12 7 7 26 372,893 2.3 2.3 Hudson Valley Region 62 51 52 165 2,261,204 2.4 2.5 New York State 866 897 940 2,703 19,254,630 4.7 4.7 Adjusted rates are age adjusted to the 2000 United States Population Source: 2004-2006 NYS Vital Statistics as of April, 2008 Exhibit 1A. 64 169

MORTALITY FROM ALL TOTAL ACCIDENTS BY GENDER, RACE, ETHNICITY, AGE GROUPS AND ZONE, ORANGE COUNTY AND UPSTATE NEW YORK, 1998-2006 Total Males+ Females+ Number of Deaths 2004 2005 2006 1998-2000 2001-2003 2004-2006 Number Number Number Number Number of Deaths of Deaths Rate of Deaths Rate Rate of Deaths Rate of Deaths Rate Rate Orange County 61 17.4 78 21.2 79 22.0 119 12.2 204 12.2 218 17.3 Upstate NY 2,849 24.3 3,118 26.6 3,204 27.3 8,301 24.7 9,161 25.4 9,171 26.0 Orange County 36 21.4 55 30.5 46 26.9 84 17.7 132 26.4 137 26.3 Upstate NY 1,827 34.5 1,995 37.2 2,083 38.6 5,419 35.4 5,818 32.8 5,905 36.8 Orange County 25 13.6 23 12.7 33 17.3 35 6.9 72 13.5 81 14.5 Upstate NY 1,022 15.0 1,123 16.7 1,121 16.9 2,882 15.5 3,343 16.8 3,266 16.2 Race/ Ethnicity White 50 16.3 65 20.5 69 22.3 112 13.4 188 19.9 184 19.7 Black s/n s/n s/n s/n s/n s/n s/n s/n s/n s/n s/n s/n Other s/n s/n s/n s/n s/n s/n s/n s/n s/n s/n s/n s/n Hispanic s/n s/n s/n s/n s/n s/n s/n s/n s/n s/n s/n s/n Age* < 5 s/n s/n s/n s/n s/n s/n s/n s/n s/n s/n s/n s/n 5-14 s/n s/n s/n s/n s/n s/n s/n s/n s/n s/n s/n s/n 15-24 s/n s/n s/n s/n s/n s/n s/n s/n s/n s/n s/n s/n 25-34 s/n s/n s/n s/n s/n s/n s/n s/n s/n s/n s/n s/n 35-44 s/n s/n s/n s/n s/n s/n s/n s/n s/n s/n s/n s/n 45-54 s/n s/n s/n s/n s/n s/n s/n s/n s/n s/n s/n s/n 55-64 s/n s/n s/n s/n s/n s/n s/n s/n s/n s/n s/n s/n 65-74 s/n s/n s/n s/n s/n s/n s/n s/n s/n s/n s/n s/n 75-84 s/n s/n s/n s/n s/n s/n s/n s/n s/n s/n s/n s/n 85+ s/n s/n s/n s/n s/n s/n s/n s/n s/n s/n s/n s/n Zones Central s/n s/n s/n s/n s/n s/n s/n s/n s/n s/n s/n s/n East s/n s/n s/n s/n s/n s/n s/n s/n s/n s/n s/n s/n Middletown City s/n s/n s/n s/n s/n s/n s/n s/n s/n s/n s/n s/n Newburgh City s/n s/n s/n s/n s/n s/n s/n s/n s/n s/n s/n s/n North s/n s/n s/n s/n s/n s/n s/n s/n s/n s/n s/n s/n Port Jervis City s/n s/n s/n s/n s/n s/n s/n s/n s/n s/n s/n s/n West s/n s/n s/n s/n s/n s/n 21 s/n s/n s/n s/n s/n Except as noted all mortality rates are age-sex adjusted to the US Census 2000 population. +Age adjusted mortality rate *Crude mortality rate (i.e., not age or sex adjusted) s/n = Data are unreliable due to small number of cases Populations used in calculating rates are from the Vintage 1990 population with bridged race estimates, Census 2000, and Vintage 2000 with bridged race estimates. Vintage data was downloaded from the National Center for Health Statistics. Population data for gender, racial and ethnic groups for Health Planning Zones was derived from the Census 2000 for these racial groups and interpolated from the Vintage estimates by town. Mortality rates are based on events with known age and gender Data Source: NYS DOH Vital Statistics. Deaths for Orange County residents that were recorded in NYC are not recorded in this analysis. Data analysis and table by the School of Public Health, University at Albany, August, 2009. Exhibit 1A.65a 170

MORTALITY FROM TOTAL ACCIDENTS BY GENDER, ORANGE COUNTY AND UPSTATE NEW YORK 1998-2006 M o t a l i t y R a t e 40.0 35.0 30.0 25.0 20.0 15.0 10.0 5.0 Orange County Upstate NY Orange County Upstate NY Males+ Females+ 1998 2000 2001 2003 2004 2006 +Age adjusted mortality rate Populations used in calculating rates are from the Vintage 1990 population with bridged race estimates, Census 2000, and Vintage 2000 with bridged race estimates. Vintage data was downloaded from the National Center for Health Statistics. Population data for gender, racial and ethnic groups for Health Planning Zones was derived from the Census 2000 for these racial groups and interpolated from the Vintage estimates by town. Mortality rates are based on events with known age and gender Data Source: NYS DOH Vital Statistics. Deaths for Orange County residents that were recorded in NYC are not recorded in this analysis. Data analysis and table by the School of Public Health, University at Albany, August, 2009. Exhibit 1A.65b 171

DISCHARGE RATES FROM UNINTENTIONAL INJURIES BY AGE, ORANGE COUNTY HUDSON VALLEY REGION AND NYS, 2004-2006 UNINTENTIONAL INJURY - DISCHARGE RATE PER 10,000 POPULATION Discharges Population Crude Adjusted Region/County 2004 2005 2006 TOTAL 2005 Rate Rate Orange 2,504 2,464 2,456 7,424 372,893 66.4 71.9 Hudson Valley Region 15,135 15,241 15,105 45,481 2,261,204 67 65 New York State 129,083 132,268 132,847 394,198 19,254,630 68.2 64.7 UNINTENTIONAL INJURY (AGE <10) - DISCHARGE RATE PER 10,000 POPULATION AGE <10 Discharges Population Crude Region/County 2004 2005 2006 TOTAL 2005 Rate Orange 150 127 122 399 52,577 25.3 Hudson Valley Region 686 696 605 1,987 296,762 22.3 New York State 7,127 6,809 6,499 20,435 2,441,693 27.9 UNINTENTIONAL INJURY (AGE 10-14) - DISCHARGE RATE PER 10,000 POPULATION AGE 10-14 Discharges Population Crude Region/County 2004 2005 2006 TOTAL 2005 Rate Orange 81 63 78 222 29,722 24.9 Hudson Valley Region 388 350 337 1,075 164,751 21.7 New York State 3,449 3,108 2,991 9,548 1,302,493 24.4 UNINTENTIONAL INJURY (AGE 15-24) - DISCHARGE RATE PER 10,000 POPULATION AGE 15-24 Discharges Population Crude Region/County 2004 2005 2006 TOTAL 2005 Rate Orange 214 239 208 661 54,468 40.5 Hudson Valley Region 1,227 1,199 1,223 3,649 300,499 40.5 New York State 9,518 9,471 9,446 28,435 2,620,399 36.2 UNINTENTIONAL INJURY (AGE 25-64) - DISCHARGE RATE PER 10,000 POPULATION AGE 25-64 Discharges Population Crude Region/County 2004 2005 2006 TOTAL 2005 Rate Orange 961 936 923 2,820 199,344 47.2 Hudson Valley Region 5,373 5,347 5,342 16,062 1,214,106 44.1 New York State 46,919 48,385 49,051 144,355 10,374,981 46.4 UNINTENTIONAL INJURY (AGE 65+) - DISCHARGE RATE PER 10,000 POPULATION AGE 65+ Discharges Population Crude Region/County 2004 2005 2006 TOTAL 2005 Rate Orange 1,098 1,099 1,125 3,322 36,782 301.1 Hudson Valley Region 7,461 7,649 7,598 22,708 285,086 265.5 New York State 62,070 64,495 64,860 191,425 2,515,064 253.7 Adjusted rates are age adjusted to the 2000 United States Population Source: 2004-2006 SPARCS Data as of March, 2008 Exhibit 1A. 66 172

UNINTENTIONAL INJURY - DEATHS AND DEATH RATES ORANGE COUNTY, HUDSON VALLEY REGION, AND NYS, 2004-2006 Deaths Population Crude Adjusted REGION/COUNTY 2004 2005 2006 TOTAL 2005 Rate Rate Orange 91 94 101 286 372,893 25.6 26.7 Hudson Valley Region 495 551 592 1,638 2,261,204 24.1 23.6 New York State 3,927 4,345 4,431 12,703 19,254,630 22 20.8 Rate per 100,000 residents Source: 2004-2006 NYSDOH Vital Statistics Data as of March, 2008 Exhibit 1A. 67 173

MORTALITY FROM MOTOR VEHICLE ACCIDENTS, ORANGE COUNTY, HUDSON VALLEY REGION, AND NYS, 2004-2006, RATES PER 100,000 RESIDENTS Deaths Population Crude Adjusted Region/County 2004 2005 2006 Total 2005 Rate Rate Orange 44 48 39 131 372,893 11.7 12 Hudson Valley Region 205 203 200 608 2,261,204 9 9 New York State 1,525 1,478 1,527 4,530 19,254,630 7.8 7.7 ALCOHOL RELATED MOTOR VEHICLE DEATHS AND INJURIES, ORANGE COUNTY, HUDSON VALLEY REGION, AND NYS, 2004-2006 - RATE PER 100,000 POPULATION Alcohol Related Motor Vehicles Population Rate Region/County 2004 2005 2006 Total 2005 Orange 239 251 259 749 372,893 67 Hudson Valley Region 1,370 1,279 1,166 3,815 2,261,204 56.2 New York State 8,406 8,106 7,690 24,202 19,254,630 41.9 Source: 2004-2006 NYS Department of Motor Vehicles Data as of June, 2008 Adjusted rates are age adjusted to the 2000 United States Population Exhibit 1A. 68 174

MORTALITY FROM MOTOR VEHICLE ACCIDENTS, ORANGE COUNTY AND UPSTATE NEW YORK, TEN YEAR TIME TREND, 1997-2006 MOTOR VEHICLE DEATH RATE PER 100,000 POPULATION Year Single Year Orange County 3-Year Average Orange County Upstate New York 1997 11.9 11.6 1998 9.9 11.7 10.9 1999 13.4 10.5 11.5 2000 8.2 10.6 10 2001 10.3 10.1 11.1 2002 11.8 11.3 11 2003 11.8 11.8 10.1 2004 11.9 12.2 10.6 2005 12.9 11.7 9.7 2006 10.4 10.1 Source: 2004-20062006 NYS Department of Motor Vehicles Data as of June, 2008 Exhibit 1A. 69 175

DISCHARGE RATES FOR TRAUMATIC BRAIN INJURY ORANGE COUNTY, HUDSON VALLEY REGION AND NYS, 2004-2006 Deaths Population Crude Adjusted REGION/COUNTY 2004 2005 2006 TOTAL 2005 Rate Rate Orange 300 280 317 897 372,893 8 8.3 Hudson Valley Region 1,825 1,840 1,984 5,649 2,261,204 8.3 8.3 New York State 15,590 15,818 16,603 48,011 19,254,630 8.3 8.1 Source: 2004-2006 SPARCS Data as of March, 2008 Rate per 10,000 population Exhibit 1A. 70 176

CASES AND RATES OF EARLY SYPHILIS (AGES 15-19), ORANGE COUNTY, HUDSON VALLEY REGION AND NYS, 2003-2005 Early Syphilis Total Population Rate* Region/County 2004 2005 2006 2005 Orange 0 0 0 0 372,893 0 Hudson Valley Region 2 1 1 4 2,261,204 0.18 New York State N/A N/A N/A 52 19,254,630 4.0 *Rate per 100,000 population age 15-19 Sources: Bureau of STD Control Data, New York State Health Information Network CASES AND RATES OF CONGENTIAL SYPHILIS, ORANGE COUNTY, HUDSON VALLEY REGION AND NYS, 2001-2003 Congential Syphilis Total Births Rate Region/County 2001 2002 2003 2001-2003 Orange 0 1 0 1 14,890 6.7 Hudson Valley Region 3 2 8 13 88,712 14.7 New York State 40 30 52 122 762,787 16 *Rate per 100,000 births Source: 2001-2003 Bureau OF STD Control Data as of June, 2006 Exhibit 1A.71 177

CASES AND RATES OF GONORRHEA (ALL AGES), ORANGE COUNTY, HUDSON VALLEY REGION AND NYS, 2004-2006 Gonorrhea Age (15-19) Total Population Rate* Region/County 2004 2005 2006 2004-2006 2005 Orange 177 113 141 431 372,893 38.5 Hudson Valley Region 967 798 854 2619 2,261,204 38.6 New York State 18,579 17,912 17,459 53950 19,254,630 93.4 CASES AND RATES OF GONORRHEA (AGES 15-19), ORANGE COUNTY, HUDSON VALLEY REGION AND NYS, 2004-2006 Gonorrhea Age (15-19) Total Population Rate* Region/County 2004 2005 2006 2004-2006 2005 Orange 38 23 23 84 29,417 95.2 Hudson Valley Region 253 186 219 658 161,827 135.5 New York State 4,572 4,459 4,176 13,207 1,318,372 333.9 *Rate: Per 100,000 Population Age 15-19 Source: 2004-2006 Bureau of STD Control Data as of June, 2008 Exhibit 1A. 72 178

CASES AND RATES OF CHLAMYDIA BY RACE AND ETHNICITY ORANGE COUNTY, HUDSON VALLEY REGION, AND NYS, 2004-2006 Orange County Hudson Valley Region NYS Excluding NYC Race Frequency Percent Frequency Percent Frequency Percent White 916 37.6% 3,546 14.9% 25,327 23.37% Black 529 21.7% 4,028 16.9% 26,569 24.53% Other Race 65 2.7% 9,039 37.9% 5,753 5.31% Race Unknown 359 14.8% 2,804 11.8% 19,695 18.18% Hispanic 393 16.2% 2,679 11.2% 8,951 8.26% Ethnicity Unknown 171 7.0% 1,739 7.3% 21,961 20.27% CASES AND RATES OF CHLAMYDIA BY AGE, ORANGE COUNTY, HUDSON VALLEY REGION, AND NYS, 2004-2006 Orange County Hudson Valley Region NYS Excluding NYC Age Intervals Frequency Percent Frequency Percent Frequency Percent 00 and < 1 3.00 0.16% 10 0.09% 51 0.10% 01-04 0.00 0.00 0.00 0.00 0.00 0.00 05-09 0.00 0.00 0.00 0.00 0.00 0.00 10-14 14.00 0.75% 129 1.10% 1,238 2.41% 15-19 653.00 34.92% 3,963 33.70% 28,133 54.98% 20-29 963.00 51.50% 6,084 51.70% 14,035 27.43% 30-39 179.00 9.57% 1,168 9.92% 6,420 12.54% 40-49 40.00 2.14% 288 2.45% 609 1.10% 50-59 11.00 0.59% 73 0.62% 375 0.70% 60 Years + 4.00 0.21% 18 0.15% 177 3.43% Age Unknown 3.00 0.16% 37 0.31% 119 0.23% CASES AND RATES OF CHLAMYDIA BY GENDER, ORANGE COUNTY, HUDSON VALLEY REGION, AND NYS, 2004-2006 Orange County Hudson Valley Region NYS Excluding NYC GENDER Frequency Percent Frequency Percent Frequency Percent Male 425.00 22.73% 2972 25.25% 20,082 26.98% Female 1,445.00 77.27% 8797 74.75% 57,335 77.02% Unknown 0.00 0.00 1 0.00 3 0.00 Source: New York State Health Information Network Created by the School of Public Health, University at Albany, August, 2009 Exhibit 1A.73 179

DISCHARGE RATES FOR PELVIC INFLAMMATORY DISEASE FEMALES (AGES 15-44), ORANGE COUNTY, HUDSON VALLEY REGION AND NYS, 2004-2006 Discharges Total Population Rate* Region/County 2004 2005 2006 2005 Orange 27 27 21 75 78,447 3.2 Hudson Valley Region 152 139 123 414 452,930 3 New York State 2,155 1,956 1,824 5,935 4,084,946 4.8 *Rate per 10,000 Females Age 15-44 Source: 2004-2006 SPARCS Data as of March, 2008 Exhibit 1A.74 180

CASES AND RATES OF AIDS, ORANGE COUNTY, HUDSON VALLEY REGION AND NYS, 2004-2006 AIDS Cases Total Population Rate* Region/County 2004 2005 2006 2005 Orange 44 45 32 121 372,893 10.8 Hudson Valley Region 308 277 257 842 2,261,204 12.4 New York State 4,803 4,625 4,298 13,726 19,254,630 23.8 *Rate per 100,000 population including all newly diagnosed HIV, regardless of concurrent or subsequent AIDS diagnosis Source: 2004-2006 Bureau of HIV/AIDS Epidemiology Data as of June, 2008 Exhibit 1A. 75a 181

CASES AND RATES OF AIDS PER 100,000, ORANGE COUNTY, HUDSON VALLEY REGION, UPSTATE NY, 1998-2006 Number of Cases 1998-2000 2001-2003 2004-2006 Average Rate over 3 years Number of Cases Average Rate over 3 years Number of Cases Average Rate over 3 years Orange County 134 13.2 139 13.0 119 10.7 HV Region 1,088 16.8 959 14.4 816 12.6 Upstate NY 3,322 10.1 3,136 9.2 2,645 8.0 HIV INFECTION RATES PER 100,000, ORANGE COUNTY, HUDSON VALLEY REGION, UPSTATE NY, 2000-2006 Number of Cases 2000-2002 2003-2005 Average Rate over 3 years Number of Cases Average Rate over 3 years Orange County 100 9.6 114 10.4 HV Region 358 5.4 399 5.9 Upstate NY 2422 7.3 2434 7.3 Data from New York State HIV/AIDS County Surveillance Report (excludes State Prison Inmates) for Cases through December 2007 Data from Hamilton County is not included. Data analysis and table prepared by SUNY Albany School of Public Health, August, 2009 HIV infection reporting began in 2000. Exhibit 1A.75b 182

PERSONS LIVING WITH AIDS AND HIV INFECTION, BY GENDER, ETHNICITY,RACE, AND AGE, AND MODE OF TRANSMISSION/RISK CATEGORY, ORANGE COUNTY, RYAN WHITE MID-HUDSON REGION, AND UPSTATE NY, CUMULATIVE TO 2006 Total Males Females Age Group <12 13-19 20-24 25-29 30-39 40-49 50-59 60 + Age Unknown Race/Ethnicity White Black Other ORANGE COUNTY* MID-HUDSON REGION UPSTATE NEW YORK LIVING AIDS PERCENT LIVING HIV PERCENT LIVING AIDS PERCENT LIVING HIV PERCENT LIVING AIDS PERCENT LIVING HIV PERCENT 524 100.0 289 100.0 1,414 100.0 789 100 12,939 100.0 7,653 100.0 367 70.0 173 59.8 964 68.2 473 59.9 8,869 68.5 4,727 61.8 157 30.0 116 40.1 450 31.8 316 40.1 4,070 31.5 2,926 38.2 5 1.7 14 1.8 16 0.1 147 1.9 11 2.1 8 2.7 21 1.5 23 2.9 143 1.1 210 2.7 3 0.6 9 3.1 11 0.8 20 2.5 157 1.2 327 4.3 4 0.8 20 6.8 23 1.6 50 6.3 272 2.1 516 6.7 70 13.4 67 22.9 195 13.8 154 19.5 2,098 16.2 1,779 23.2 212 40.5 108 37.0 569 40.2 305 38.7 5,343 41.3 2,719 35.5 161 30.7 54 18.5 455 32.2 170 21.5 3,690 28.5 1,490 19.5 63 12.0 17 5.8 140 9.9 52 6.6 1,087 8.4 457 6.0 0 0.0 1 0.3 0 0.0 1 0.1 1 0.0 8 0.1 153 29.2 106 36.3 489 34.6 309 39.2 4,792 37.0 3,038 39.7 206 39.3 97 33.2 219 15.5 284 36.0 5,171 40.0 2,903 37.9 27 5.2 20 6.8 405 28.6 60 7.6 555 4.3 389 5.1 137 26.1 66 22.6 325 23.0 136 17.2 2,280 17.6 1,309 17.1 1 0.2 1 0.3 1 0.1 14 0.2 Hispanic Race Unknown Mode of Transmission MSM 95 18.1 74 25.3 277 19.6 185 23.4 3,715 28.7 2,435 31.8 IDU 176 33.6 56 19.2 514 36.4 197 25.0 3,451 26.7 1,146 15.0 MSM/IDU 24 4.6 6 2.1 67 4.7 29 3.7 533 4.1 200 2.6 Heterosexual 151 28.8 87 29.8 347 24.5 229 29.0 2,661 20.6 1,828 23.9 Blood Products 5 1.0 2 0.7 8 0.6 3 0.4 113 0.9 35 0.5 Pediatric Risk 10 1.9 10 3.4 21 1.5 30 3.8 196 1.5 296 3.9 Unknown Risk 63 12.0 54 18.5 180 12.7 116 14.7 2,138 16.5 1,713 22.4 Data for Upstate NY and Mid-Hudson Ryan White Region obtained from the New York State HIV/AIDS Surveillance Annual Report for Cases Diagnosed Through 2006, excluding state prison inmates. Data for Orange County was obtained from New York State HIV/AIDS County Surveillance Report Excluding State Prison Inmates for Cases Diagnosed Through December 2007. *Data for Orange County includes 28 additional cases diagnosed between Jan. 2007 and Dec. 2007. Exhibit 1A.75c 183

TRENDS IN AIDS MORTALITY, ORANGE COUNTY AND UPSTATE NEW YORK, TEN YEAR TIME TRENDS, 1997-2006 AIDS DEATH RATE PER 100,000 POPULATION Year Single Year Orange County 3-Year Average Orange County Upstate New York 1997 5.2 4 1998 4.2 4.6 3.2 1999 4.5 5.1 3.7 2000 6.7 4.9 3.5 2001 3.4 4.2 3.1 2002 2.5 3.6 2.8 2003 4.7 3.4 2.6 2004 3 3.6 2.8 2005 3.2 3 2.4 2006 2.9 2.6 AIDS DEATH AND DEATH RATES PER 100,000 RESIDENTS, ORANGE COUNTY, HUDSON VALLEY REGION AND NYS, 2004-2006 Deaths Total Population Crude Adjusted Region/County 2004 2005 2006 2004-2006 2005 Rate Rate Orange 11 12 11 34 372,893 3 3 Hudson Valley Region 83 73 54 210 2,261,204 3.1 2.9 New York State 1,722 1,646 1,456 4824 19,254,630 8.4 8 Source: 2004-2006 Vital Statistics Data as of March, 2008 Exhibit 1A. 76a 184

TRENDS IN AIDS MORTALITY PER 100,000, ORANGE COUNTY, HUDSON VALLEY REGION, NEW YORK STATE, TEN YEAR TIME TREND, 1997-2006 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 Orange County 4.07 2.87 2.83 3.4 2.83 2.83 4.25 2.83 3.68 2.83 HV Region 4.75 4.63 4.61 4.98 3.77 3.96 3.35 3.44 3.02 2.19 New York State 16.21 12.17 12.71 12.29 11.15 10.67 10.17 9.23 8.79 7.78 TRENDS IN AIDS MORTALITY PER 100,000, ORANGE COUNTY, HUDSON VALLEY REGION, NEW YORK STATE, TEN YEAR TIME TREND, 1997-2006 18 16 14 Rate per 100,000 12 10 8 6 4 2 0 Orange County HV Region New York State Region 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 Data from New York State Department of Health, Health Information Network Table prepared by SUNY Albany School of Public Health, August 2009 Exhibit 1A.76b 185

HIV POSITIVE NEWBORNS, ORANGE COUNTY, HUDSON VALLEY REGION AND NYS, 2001-2003 HIV Positive Newborns Newborns Tested Rate* Region/County 2001 2002 2003 Total 2001-2003 Orange 9 3 4 16 372,893 0 Hudson Valley Region 113 99 116 328 2,261,204 0.1 New York State 1,363 1,289 1,270 3,922 19,254,630 0.2 *Rate HIV Positive Newborns Per 1,000 Newborns Tested Source: 2001-2003 Bureau of HIV/AIDS Epidemiology Data as of June, 2008 Exhibit 1A. 77 186

CASES AND RATES OF TUBERCULOSIS IN ORANGE COUNTY, HUDSON VALLEY REGION, AND NYS 2004-2006 Tuberculosis Population Rate* Region/County 2004 2005 2006 Total 2005 Orange 9 3 4 16 372,893 1.4 Hudson Valley Region 113 99 116 328 2,261,204 4.8 New York State 1,363 1,289 1,270 3,922 19,254,630 6.8 *Rate per 100,000 population Source: 2004-2006 Bureau of Communicable Disease Control Data as of June, 2008 Created by the School of Public Health, University at Albany, August, 2009 Exhibit 1A. 78a 187

CASES AND RATES OF TUBERCULOSIS BY RACE AND ETHNICITY ORANGE COUNTY, HUDSON VALLEY REGION, AND UPSTATE NY, 2004-2006 Orange County Hudson Valley Region NYS Excluding NYC Race Frequency Percent Frequency Percent Frequency Percent White 10 47.61% 164 35.87% 482 38.78% Black 4 19.05% 79 17.29% 240 19.31% Other Race 2 9.52% 74 16.20% 223 17.94% Race Unknown 0 0.00% 0 0.00% 1 0.08% Hispanic 5 23.81% 140 30.63% 293 23.57% CASES AND RATES OF TUBERCULOSIS BY AGE, ORANGE COUNTY, HUDSON VALLEY REGION, AND UPSTATE NY, 2004-2006 Orange County Hudson Valley Region NYS Excluding NYC Age Intervals Frequency Percent Frequency Percent Frequency Percent 00 and < 1 0 0.00% 2 0.59% 6 0.06% 01-04 0 0.00% 6 1.77% 25 2.64% 05-09 0 0.00% 2 0.59% 10 1.06% 10-14 0 0.00% 4 1.18% 19 2.01% 15-19 0 0.00% 10 2.95% 35 3.07% 20-29 2 12.50% 83 24.48% 185 19.56% 30-39 1 6.25% 78 23.01% 155 16.38% 40-49 3 18.75% 50 14.75% 153 16.17% 50-59 2 12.50% 36 10.62% 123 13.00% 60 Years + 8 50.00% 68 20.06% 235 24.84% CASES AND RATES OF TUBERCULOSIS BY GENDER, ORANGE COUNTY, HUDSON VALLEY REGION, AND UPSTATE NY, 2004-2006 Orange County Hudson Valley Region NYS Excluding NYC Gender Frequency Percent Frequency Percent Frequency Percent Male 10.00 50.00% 181 54.52% 564 59.62% Female 10.00 50.00% 151 45.78% 382 40.38% Source: New York State Health Information Network Data analysis and table by SUNY Albany School of Public Health, August, 2009 Exhibit 1A.78b 188

TOTAL CASES AND RATES OF SELECTED COMMUNICABLE DISEASES, ORANGE COUNTY, HUDSON VALLEY AND NYS, 2004-2006 Orange County Hudson Valley Region NYS Excluding NYC New York State Disease Frequency Rate/100,000 Frequency Rate/100,000 Frequency Rate/100,000 Frequency Rate/100,000 Camplylobacteriosis 103 27.6 893 39.5 4,220 38.0 6,870 35.7 Ehrilichiosis 20 5.4 545 24.1 744 6.7 804 4.2 Escherichia Coli O157:H7 5 1.3 56 2.5 397 3.6 483 2.5 Giardiasis 94 25.2 803 35.5 4,314 38.8 7,208 37.4 Haemophilus Influenzae 8 2.1 60 2.7 442 4.0 695 3.6 Hepatitis A 7 1.9 79 3.5 334 3.0 1086 5.6 Hepatitis B 4 1.1 40 1.8 275 2.5 692 3.6 Lyme Disease 1,521 407.9 8,763 387.5 14,064 126.6 15,125 78.6 Measles N/A N/A 2 0.1 9 0.1 9 0.0 Meningitis Other, Unknown 6 1.6 51 2.3 264 2.4 516 2.7 Meningitis, Viral 51 13.7 207 9.2 1,772 15.9 3,309 17.2 Meningococcal Disease 4 1.1 23 1.0 133 1.2 243 1.3 Mumps 1 0.3 36 1.6 89 0.8 89 0.5 Pertussis 214 57.4 775 34.3 3,708 33.4 3,708 19.3 Rubella N/A N/A N/A N/A 2 0.0 2 0.0 Rubella, Congenital N/A N/A N/A N/A N/A N/A N/A N/A Salmonellosis 143 38.3 871 38.5 4,141 37.3 7,875 40.9 Shigellosis 70 18.8 379 16.8 1,028 9.3 2,137 11.1 Streptococcal, Group B 28 7.5 305 13.5 2,114 19.0 3,384 17.6 Streptococcus Pneu, Not Drug Resist.* 99 26.5 591 26.1 3,411 30.7 3,411 17.7 Streptococcus Pneu., Drug Resist.* 6 1.6 40 1.8 232 2.1 232 1.2 Source: NYSDOH Health Information Network N/A: Not available *Streptococcus Pneu. case numbers not available for NYC Exhibit 1A.79 189

MORTALITY FROM PNEUMONIA BY GENDER, RACE, ETHNICITY, AGE GROUPS AND HEALTH PLANNING ZONES, ORANGE COUNTY AND UPSTATE NEW YORK, 1998-2006 2004 2005 2006 1998-2000 2001-2003 2004-2006 Number Number Number Number Number Number of Deaths Rate of Deaths Rate of Deaths Rate of Deaths Rate of Deaths Rate of Deaths Rate Total Orange County 76 17.4 89 21.1 88 22.0 212 12.2 244 19.9 253 20.2 Upstate NY 2,669 20.7 2,675 20.9 2,347 18.2 9,822 27.3 8,347 21.5 7,691 20.0 Males+ Orange County 30 21.4 28 30.5 48 26.9 97 17.7 100 26.5 106 26.3 Upstate NY 1,176 23.2 1,181 23.5 1,048 20.6 4,398 31.7 3,663 19.8 3,405 22.6 Females+ Orange County 46 13.6 61 12.7 40 17.3 115 6.9 144 13.5 147 14.5 HV Region Upstate NY 1,493 19.0 1,494 19.0 1,299 16.6 5,424 24.2 4,684 20.2 4,286 18.2 Race/ Ethnicity White 65 16.3 80 20.5 81 22.3 204 13.3 232 20.7 226 19.7 Black s/n s/n s/n s/n s/n s/n s/n s/n s/n s/n s/n s/n Other s/n s/n s/n s/n s/n s/n s/n s/n s/n s/n s/n s/n Hispanic s/n s/n s/n s/n s/n s/n s/n s/n s/n s/n s/n s/n Age* < 5 s/n s/n s/n s/n s/n s/n s/n s/n s/n s/n s/n s/n 5-14 s/n s/n s/n s/n s/n s/n s/n s/n s/n s/n s/n s/n 15-24 s/n s/n s/n s/n s/n s/n s/n s/n s/n s/n s/n s/n 25-34 s/n s/n s/n s/n s/n s/n s/n s/n s/n s/n s/n s/n 35-44 s/n s/n s/n s/n s/n s/n s/n s/n s/n s/n s/n s/n 45-54 s/n s/n s/n s/n s/n s/n s/n s/n s/n s/n s/n s/n 55-64 s/n s/n s/n s/n s/n s/n s/n s/n s/n s/n s/n s/n 65-74 s/n s/n s/n s/n s/n s/n 25 12.7 s/n s/n s/n s/n 75-84 22 s/n 34 s/n 25 s/n 61 19.2 68 56.0 81 19.2 85+ 84 s/n 41 s/n 41 s/n 111 66.8 131 83.0 116 66.8 Zones Central 23 s/n 21 s/n 28 s/n 76 71.1 80 72.0 72 70.2 East s/n s/n 31 s/n 21 s/n 29 74.2 66 52.3 69 96.2 Middletown City s/n s/n s/n s/n s/n s/n 21 67.5 29 61.8 24 75.3 Newburgh City s/n s/n s/n s/n s/n s/n s/n s/n s/n s/n 25 s/n North s/n s/n s/n s/n s/n s/n 34 s/n 24 s/n 31 s/n Port Jervis City s/n s/n s/n s/n s/n s/n s/n s/n s/n s/n s/n s/n West s/n s/n s/n s/n s/n s/n 35 73.1 29 73.1 26 65.5 Rates per 100,000 population Except as noted all mortality rates are age-sex adjusted to the US Census 2000 population. +Age adjusted mortality rate *Crude mortality rate (i.e., not age or sex adjusted) s/n = Data are unreliable due to small number of cases Populations used in calculating rates are from the Vintage 1990 population with bridged race estimates, Census 2000, and Vintage 2000 with bridged race estimates. Vintage data was downloaded from the National Center for Health Statistics. Population data for gender, racial and ethnic groups for Health Planning Zones was derived from the Census 2000 for these racial groups and interpolated from the Vintage estimates by town. Mortality rates are based on events with known age and gender Data Source: NYS DOH Vital Statistics. Deaths for Orange County residents that were recorded in NYC are not recorded in this analysis. Data analysis and table by the School of Public Health, University at Albany, August, 2009. Exhibit 1A.80 190

MORTALITY FROM ALL CARDIOVASCULAR DISEASES BY GENDER, RACE, ETHNICITY, AGE GROUPS AND HEALTH PLANNING ZONES, ORANGE COUNTY, 1998-2006 Number Number Number Number Number Number of Deaths Rate of Deaths Rate of Deaths Rate of Deaths Rate of Deaths Rate of Deaths Rate Total Orange County 897 282.3 837 262.9 835 256.7 1,975 226.9 2,776 300.7 2,569 267.2 Males+ Orange County 401 333.6 374 308.3 367 291.8 895 266.4 1,213 345.1 1,142 311.0 Females+ Orange County 496 244.5 463 229.1 468 228.1 1,080 192.9 1,563 263.4 1,427 233.9 Race/ Ethnicity White 823 275.9 757 254.9 769 254.2 1,863 229.3 2,578 296.9 2,349 261.5 Black 56 340.2 53 280.3 45 240.8 104 241.3 176 356.8 154 285.8 Other s/n s/n 25 570.1 s/n s/n s/n 130.1 20 210.3 62 463.0 Hispanic 32 169.4 38 219.1 32 149.0 56 155.9 97 111.0 102 177.2 Age* < 5 s/n s/n s/n s/n s/n s/n s/n s/n s/n s/n s/n s/n 5-14 s/n s/n s/n s/n s/n s/n s/n s/n s/n s/n s/n s/n 15-24 s/n s/n s/n s/n s/n s/n s/n s/n s/n s/n s/n s/n 25-34 s/n s/n s/n s/n s/n s/n s/n s/n s/n s/n s/n s/n 35-44 22 37.9 s/n s/n s/n s/n 33 18.8 55 31.1 50 29.3 45-54 38 71.1 45 82.4 41 73.7 97 71.1 129 84.6 124 75.7 55-64 78 227.3 57 159.3 65 174.8 169 211.2 224 243.0 200 186.4 65-74 102 542.7 120 632.4 118 611.6 342 622.6 416 751.6 340 595.8 75-84 267 2,128.3 259 2,067.8 231 1,853.8 594 1,631.2 823 2,192.9 757 2,017.0 85+ 384 7,709.3 335 6,617.9 358 6,917.9 727 5,401.6 1,110 7,676.4 1,077 7,077.2 Zones Central 227 283.9 203 253.2 214 262.4 523 255.3 678 295.7 644 266.4 East 264 286.3 256 276.1 232 252.3 549 214.1 796 299.1 752 271.6 Middletown City 95 341.8 63 234.4 73 272.6 186 211.8 285 358.5 231 282.5 Newburgh City 83 375.2 79 357.1 66 312.1 166 268.2 264 406.1 228 348.7 North 78 242.0 79 249.1 69 211.9 184 209.7 243 264.1 226 234.2 Port Jervis City 35 308.5 42 365.1 33 294.1 92 290.2 105 310.0 110 322.7 West 115 220.0 115 223.0 148 278.4 275 192.8 405 269.3 378 242.1 Rates Per 100,000 population Except as noted all mortality rates are age-sex adjusted to the US Census 2000 Population. +Age adjusted mortality rate *Crude mortality rate (i.e., not age or sex adjusted) **COPD=Chronic Obstructive Pulmonary Disease, CLRD=Chronic Lower Respiratory Disease s/n = Data are unreliable due to small number of cases 2004 2005 2006 1998-2000 2001-2003 2004-2006 Populations used in calculating rates are from the Vintage 1990 population with bridged race estimates, Census 2000, and Vintage 2000 with bridged race estimates. Vintage data was downloaded from the National Center for Health Statistics. Population data for gender, racial and ethnic groups for Health Planning Zones was derived from the Census 2000 for these racial groups and interpolated from the Vintage estimates by town. Mortality rates are based on events with known age and gender Data Source: NYS DOH Vital Statistics. Deaths for Orange County residents that were recorded in NYC are not recorded in this analysis. Data analysis and table by the School of Public Health, University at Albany, August, 2009. Exhibit 1A.81 191

TRENDS IN CARDIOVASCULAR DISEASE MORTALITY, ORANGE COUNTY, UPSTATE NEW YORK, TEN YEAR TIME TRENDS, 1997-2006 DEATHS AND DEATH RATES OF CARDIOVASCULAR DISEASE PER 100,000 POPULATION Year Single Year Orange County 3-Year Average Orange County Upstate New York 1997 333.9 391.8 1998 302.5 313.3 385.3 1999 303.9 298.6 381.2 2000 289.7 290.6 377.6 2001 278.7 277.4 367.1 2002 264.3 267.8 364.2 2003 260.8 256.9 354.5 2004 246 245.1 333.7 2005 229 232.7 331.9 2006 223.2 318.8 DEATHS AND DEATH RATES OF CARDIOVASCULAR DISEASE PER 100,000 POPULATION Deaths Population Crude Adjusted Region/County 2004 2005 2006 Total 2005 Rate Rate Orange 911 854 840 2,605 372,893 232.9 271.1 Hudson Valley Region 6,511 6,393 6,356 19,260 2,261,204 283.9 264.7 New York State 62,725 62,477 60,078 185,280 19,254,630 320.8 285 Source: 2004-2006 Vital Statistics Data as of March, 2008 Rates per 100,000 population Adjusted rates are age adjusted to the 2000 United States Population Exhibit 1A. 82a 192

TRENDS IN CEREBROVASCULAR DISEASE (STROKE) MORTALITY, ORANGE COUNTY, UPSTATE NEW YORK, TEN YEAR TIME TRENDS, 1997-2006 DEATHS AND DEATH RATES OF CEREBROVASCULAR DISEASE (STROKE) PER 100,000 Year Single Year Orange County 3-Year Average Orange County Upstate New York 1997 36.5 52.7 1998 43.9 40.5 52.2 1999 41 42.2 54.8 2000 41.7 37.7 53.8 2001 30.6 35.8 51.6 2002 35.3 33.1 51 2003 33.3 34.3 48.2 2004 34.3 33.4 45.2 2005 32.7 32.4 44.1 2006 30.3 41.5 DEATHS AND DEATH RATES OF CEREBROVASCULAR DISEASE (STROKE) PER 100,000 Deaths Population Crude Adjusted Region/County 2004 2005 2006 Total 2005 Rate Rate Orange 127 122 114 363 372,893 32.4 38.1 Hudson Valley Region 833 803 832 2,468 2,261,204 36.4 33.9 New York State 6,855 6,566 6,310 19,731 19,254,630 34.2 30.5 Adjusted rates are age adjusted to the 2000 United States Population. Rates per 100,000 population Source: 2004-2006 Vital Statistics Data as of March, 2008 Exhibit 1A. 82b 193

TRENDS IN DISEASES OF THE HEART MORTALITY, ORANGE COUNTY, UPSTATE NEW YORK, TEN YEAR TIME TRENDS, 1997-2006 DEATHS AND DEATH RATES OF DISEASES OF THE HEART PER 100,000 Year Single Year Orange County 3-Year Average Orange County Upstate New York 1997 281.9 316.9 1998 243.8 258.3 312.6 1999 249.5 242.1 305.4 2000 233.2 236.9 302.5 2001 228.3 224.9 293.7 2002 213.6 216.8 291.5 2003 209 204.3 283.8 2004 190.6 193.2 267 2005 180.5 182.7 265.5 2006 177.2 257.2 DEATHS AND DEATH RATES OF DISEASES OF THE HEART PER 100,000 Deaths Population Crude Adjusted Region/County 2004 2005 2006 Total 2005 Rate Rate Orange 706 673 667 2,046 372,893 182.9 212.7 Hudson Valley Region 5,247 5,208 5,109 15,564 2,261,204 229.4 213.8 New York State 52,131 52,002 50,202 154,335 19,254,630 267.2 237.2 Adjusted rates are age adjusted to the 2000 United States Population Rates per 100,000 population Source: 2004-2006 Vital Statistics Data as of March, 2008 Exhibit 1A. 82c 194

ADMISSION RATES FOR PREVENTION QUALITY INDICATORS FOR ORANGE COUNTY, ADULT POPULATION, 20 FOR ALL ORANGE COUNTY ZIP CODES All Indicators Acute Diabetes Circulatory Respir Area Population (Age 18+) 269,292 269,292 269,292 269,292 Admissions for Condition 4,398 1,649 582 1,329 Area Rate* 1,633 613 217 494 Admission as % of Expected 100% 107% 82% 104% Statewide Rate 1,854 666 283 554 Area Rate Adjusted for Sex and Age* 1,855 711 231 575 FOR MIDDLETOWN ZIP CODES All Indicators Acute Diabetes Circulatory Respir Area Population (Age 18+) 45,389 45,389 45,389 45,389 Admissions for Condition 925 341 127 250 Area Rate* 2,039 751 280 551 Admission as % of Expected 121% 125% 105% 111% Statewide Rate 1,854 666 283 554 Area Rate Adjusted for Sex and Age* 2,237 832 293 615 FOR NEWBURGH ZIP CODE All Indicators Acute Diabetes Circulatory Respir Area Population (Age 18+) 40,472 40,472 40,472 40,472 Admissions for Condition 838 267 129 291 Area Rate* 2,072 661 320 720 Admission as % of Expected 125% 112% 121% 148% Statewide Rate 1,854 666 283 554 Area Rate Adjusted for Sex and Age* 2,310 744 341 821 FOR PORT JERVIS ZIP CODE All Indicators Acute Diabetes Circulatory Respir Area Population (Age 18+) 10,775 10,775 10,775 10,775 Admissions for Condition 257 76 43 71 Area Rate* 2,390 705 404 664 Admission as % of Expected 128% 105% 141% 118% Statewide Rate 1,854 666 283 554 Area Rate Adjusted for Sex and Age* 2,372 698 399 654 Acute disease includes dehydration, bacteral pneumonia, and urinary tract infections *Per 100,000 adult residents Source: New York State Prevention Quality Indicators https://apps.nyhealth.gov/statistics/prevention/quality_indicators/start.map Exhibit 1A.83a 195

DISCHARGE RATES FOR DISEASES OF THE HEART PER 10,000 ORANGE COUNTY, HUDSON VALLEY REGION, NEW YORK STATE, BY GENDER, 2004-2006 Male Female Region Count Rate Count Rate Orange County 7,802 145.34 6,670 127.73 Hudson Valley Region 46,026 144.96 37,136 113.5 New York State 438,532 161.08 377,414 130.63 DISCHARGE RATE FOR CARDIOVASCULAR DISEASES PER 10,000, ORANGE COUNTY, HUDSON VALLEY REGION, NEW YORK STATE, BY GENDER, 2004-2006 Male Female Region Count Rate Count Rate Orange County 10,583 197.15 9,674 185.26 Hudson Valley Region 63,563 200.19 55,392 169.3 New York State 602,344 221.25 555,792 192.36 DISCHARGE RATE FOR CEREBROVASCULAR DISEASE PER 10,000, ORANGE COUNTY, HUDSON VALLEY REGION, NEW YORK STATE, BY GENDER, 2004-2006 Male Female Region Count Rate Count Rate Orange County 1,394 25.97 1,713 32.8 Hudson Valley Region 8,938 28.15 10,131 30.96 New York State 76,836 28.22 92,074 31.87 Source: 2004-2006 SPARCS Data from the Health Information Network (HIN) as of August, 2009 Table prepared by SUNY Albany School of Public Health, August, 2009 Exhibit 1A.83b 196

MORTALITY FROM DISEASES OF THE HEART BY GENDER, RACE, ETHNICITY, AGE GROUPS AND HEALTH PLANNING ZONES, BY ORANGE COUNTY AND UPSTATE NEW YORK, 1998-2006 Number of Deaths 2004 2005 2006 1998-2000 2001-2003 2004-2006 Number Number Number of Deaths Number Rate of Deaths Rate Number of Deaths Rate Rate of Deaths Rate of Deaths Rate Orange County 672 210.8 633 198.5 636 195.8 1,552 177.7 2,164 234.4 1,941 201.6 Total Upstate NY 29,701 233.5 29,501 230.8 29,484 221.7 104,704 280.1 96,271 239.7 87,727 228.1 Orange Males+ County 314 257.1 291 239.3 289 228.3 745 219.2 972 275.6 894 241.4 Upstate NY 13,628 205.6 13,691 264.2 13,411 256.3 46,568 324.5 44,337 220.9 40,730 262.9 Orange Females+ County 358 176.3 342 169.2 347 169.1 807 144.8 1,192 201.6 1,047 171.5 Upstate NY 16,073 265.9 15,810 202.8 16,073 193.0 54,136 243.0 51,934 225.0 46,997 200.4 Race/ Ethnicity White 622 208.2 575 193.7 584 193.1 1,458 179.6 2,015 232.2 1,781 193.2 Black 40 4,374.2 43 3,894.4 34 3,724.9 89 201.1 134 272.8 117 222.8 Other s/n s/n s/n s/n s/n s/n s/n s/n s/n s/n 39 34.6 Hispanic 26 s/n 28 s/n 28 s/n 44 121.6 63 143.1 82 141.0 Age* < 5 0 s/n s/n s/n s/n s/n 0 s/n s/n s/n s/n s/n 5-14 0 s/n 0 s/n s/n s/n 0 s/n s/n s/n s/n s/n 15-24 s/n s/n s/n s/n s/n s/n s/n s/n s/n s/n s/n s/n 25-34 s/n s/n s/n s/n s/n s/n s/n s/n s/n s/n s/n s/n 35-44 s/n s/n s/n s/n s/n s/n 28 16.0 45 25.4 39 22.9 45-54 31 s/n 37 s/n 30 s/n 84 61.5 103 67.5 98 59.9 55-64 61 731.4 43 709.8 51 721.0 148 184.9 190 206.1 155 144.5 65-74 80 2,149.5 87 2,102.8 90 2,042.2 279 507.9 338 610.7 257 450.4 75-84 190 5,165.6 199 5,229.5 182 5,007.6 463 1,271.4 631 1,681.3 571 1,521.4 85+ 287 15,137.5 249 14,638.5 266 13,990.3 540 4,012.2 847 5,857.5 802 5,270.1 Zones Central 153 191.4 149 187.1 156 191.5 388 189.4 502 217.3 458 190.1 East 208 225.7 198 213.8 184 200.8 450 175.2 650 243.3 590 213.4 Middletown City 71 258.4 44 164.1 50 190.8 145 168.8 223 280.1 165 204.2 Newburgh City 65 294.4 64 280.0 51 242.0 134 217.8 209 323.3 180 276.4 North 61 190.8 60 185.5 47 145.4 153 174.1 176 190.6 168 173.8 Port Jervis City 27 241.3 33 286.6 26 236.1 80 254.3 79 234.0 86 254.7 West 87 196.5 85 163.9 122 229.0 202 140.6 325 215.3 294 187.4 Rates per 100,000 population Except as noted all mortality rates are age-sex adjusted to the US Census 2000 population. +Age adjusted mortality rate *Crude mortality rate (i.e., not age or sex adjusted) s/n = Data are unreliable due to small number of cases Populations used in calculating rates are from the Vintage 1990 population with bridged race estimates, Census 2000, and Vintage 2000 with bridged race estimates. Vintage data was downloaded from the National Center for Health Statistics. Population data for gender, racial and ethnic groups for Health Planning Zones was derived from the Census 2000 for these racial groups and interpolated from the Vintage estimates by town. Mortality rates are based on events with known age and gender Data Source: NYS DOH Vital Statistics. Deaths for Orange County residents that were recorded in NYC are not recorded in this analysis. Data analysis and table by the School of Public Health, University at Albany, August, 2009. Exhibit 1A.84a 197

MORTALITY RATES FOR DISEASES OF THE HEART BY GENDER, ORANGE COUNTY AND UPSTATE NY, 1998-2006 M o r t a l i t y R a t e 350.0 300.0 250.0 200.0 150.0 100.0 50.0 Orange County Upstate NY Orange County Upstate NY Males+ Females+ 1998 2000 2001 2003 2004 2006 Except as noted all mortality rates are age-sex adjusted to the US Census 2000 population. +Age adjusted mortality rate Populations used in calculating rates are from the Vintage 1990 population with bridged race estimates, Census 2000, and Vintage 2000 w bridged race estimates. Vintage data was downloaded from the National Center for Health Statistics. Mortality rates are based on events with known age and gender. Data Source: NYS DOH Vital Statistics. Deaths for Orange County residents that were recorded in NYC are not recorded in this analysis. Data analysis and table by the School of Public Health, University at Albany, August, 2009. Exhibit 1A.84b 198

MORTALITY FROM CEREBROVASCULAR DISEASE BY BY GENDER, RACE, ETHNICITY, AGE GROUPS AND HEALTH PLANNING ZONES, ORANGE COUNTY AND UPSTATE NY, 1998-2006 Number of Deaths 2004 2005 2006 1998-2000 2001-2003 2004-2006 Number Number Number Number Number of Deaths of Deaths Rate Rate of Deaths Rate of Deaths Rate Rate of Deaths Rate Orange County 126 40.3 122 38.5 116 35.7 278 31.8 343 37.1 364 38.2 Total Upstate NY 4,916 39.6 4,904 38.4 4,717 35.5 17,596 48.7 16,678 42.3 14,537 37.9 Orange Males+ County 55 49.7 48 39.5 43 34.7 94 30.3 131 38.3 146 41.2 Upstate NY 1,779 37.6 1,878 36.6 1,896 34.3 6,562 46.5 6,344 32.4 5,553 36.1 Orange Females+ County 71 35.1 74 37.1 73 35.5 186 32.0 212 35.3 218 35.9 Upstate NY 3,137 40.4 3,026 38.8 2,821 36.2 11,034 49.4 10,334 44.7 8,984 38.5 Race/ Ethnicity White 111 37.6 106 35.3 107 35.5 266 32.6 317 36.4 324 36.2 Black s/n s/n s/n s/n s/n s/n s/n s/n 21 44.8 20 33.5 Other s/n s/n s/n s/n s/n s/n s/n s/n s/n s/n 20 6.4 Hispanic s/n s/n s/n s/n s/n s/n s/n s/n 23 51.2 12 21.3 Age* < 5 s/n s/n s/n s/n 0 s/n s/n s/n 0 s/n 0 s/n 5-14 s/n s/n s/n s/n 0 s/n 0 s/n 0 s/n 0 s/n 15-24 s/n s/n s/n s/n 0 s/n 0 s/n s/n s/n 0 s/n 25-34 s/n s/n s/n s/n 0 s/n s/n s/n s/n s/n 0 s/n 35-44 s/n s/n s/n s/n s/n s/n s/n s/n s/n s/n s/n s/n 45-54 s/n s/n s/n s/n s/n s/n s/n s/n s/n s/n s/n s/n 55-64 s/n s/n s/n s/n s/n s/n s/n s/n s/n s/n 25 23.3 65-74 s/n s/n 25 131.8 s/n s/n 29 52.8 42 75.9 54 94.6 75-84 44 350.7 33 263.5 31 248.8 87 238.8 109 290.4 108 287.8 85+ 56 1,124.3 47 928.5 52 1,004.8 134 995.6 148 1,023.5 155 1,018.5 Zones Central 42 54.9 32 40.7 34 41.9 92 44.8 92 41.4 108 45.7 East 37 40.0 38 40.3 30 32.1 65 25.8 94 35.8 105 37.5 Middletown City s/n s/n s/n s/n s/n s/n 25 s/n 28 34.3 24 28.7 Newburgh City s/n s/n s/n s/n s/n s/n 23 s/n 30 45.1 34 28.3 North s/n s/n s/n s/n s/n s/n 21 s/n 39 42.9 31 32.7 Port Jervis City s/n s/n s/n s/n s/n s/n s/n s/n s/n s/n s/n s/n West s/n s/n 20 s/n s/n s/n 44 s/n 44 s/n 51 s/n Rates per 100,000 population Except as noted all mortality rates are age-sex adjusted to the US Census 2000 population. +Age adjusted mortality rate *Crude mortality rate (i.e., not age or sex adjusted) s/n = Data are unreliable due to small number of cases Populations used in calculating rates are from the Vintage 1990 population with bridged race estimates, Census 2000, and Vintage 2000 with bridged race estimates. Vintage data was downloaded from the National Center for Health Statistics. Population data for gender, racial and ethnic groups for Health Planning Zones was derived from the Census 2000 for these racial groups and interpolated from the Vintage estimates by town. Mortality rates are based on events with known age and gender Data Source: NYS DOH Vital Statistics. Deaths for Orange County residents that were recorded in NYC are not recorded in this analysis. Data analysis and table by the School of Public Health, University at Albany, August, 2009. Exhibit 1A.85a 199

MORTALITY FROM CEREBROVASCULAR DISEASE BY GENDER, ORANGE COUNTY, UPSTATE NY 1998-2006 M O R T A L I T Y R A T E 60.0 50.0 40.0 30.0 20.0 10.0 Orange County Upstate NY Orange County Upstate NY +Males +Females 1998 2000 2001 2003 2004 2006 Except as noted all mortality rates are age-sex adjusted to the US Census 2000 population. +Age adjusted mortality rate Populations used in calculating rates are from the Vintage 1990 population with bridged race estimates, Census 2000, and Vintage 2000 with bridg race estimates. Vintage data was downloaded from the National Center for Health Statistics. Mortality rates are based on events with known age and gender Data Source: NYS DOH Vital Statistics. Deaths for Orange County residents that were recorded in NYC are not recorded in this analysis. Data analysis and table by the School of Public Health, University at Albany, August, 2009. Exhibit 1A.85b 200

CANCER INCIDENCE AND MORTALITY ORANGE COUNTY, NEW YORK STATE, 2001-2005 HP 2010 Target for Mortality: 160/100,000 Incidence Mortality Site of Cancer All Invasive Malignant Tumors Average Annual Cases Males Females Males Females Rate per Average Rate per Average Rate per Average Rate per 100,000 Males 95% CI (+/-) Annual Cases 100,000 Females 95% CI (+/-) Annual Deaths 100,000 Males 95% CI (+/-) Annual Deaths 100,000 Females 95% CI (+/-) 830.2 590.7 18.6 832.2 468.5 14.3 299 234.4 12.3 321.8 179.6 8.9 Incidence data are provisional, January 2008 Rates are per 100,000 persons, age-adjusted to the 2000 US standard population, with 95% confidence intervals. Rates based on fewer than 4 cases or deaths per year are unstable and should be used with caution. Source: New York State Cancer Registry Exhibit 1 A. 86 201

TRENDS IN CANCER INCIDENCE AND MORTALITY BY GENDER, COUNTY AND NYS, 1976-2005 New York State Cancer Incidence Rate by Gender 1976-1981 1982-1986 1987-1991 1992-1996 1997-2001 2001-2005 Avg. Adj 95% Avg. Adj 95% Avg. Adj 95% Avg. Adj 95% Avg. Adj 95% Avg. 95% CI Site of Cancer Deaths Rate (+/-) Deaths Rate (+/-) Deaths Rate (+/-) Deaths Rate (+/-) Deaths Rate (+/-) Cases Adj Rate (+/-) Cancer Incidence among Males All Invasive Malignant Tumors 40111 486.1 2.2 36494.4 516.4 2.5 38723.4 532.3 2.5 43775.6 574.2 2.5 45977.4 570.2 2.4 48591 567 2.3 Cancer Incidence among Females All Invasive Malignant Tumors 41952 364 1.6 38318.4 386.1 1.8 40699 400.8 1.8 43882.8 421.8 1.8 46943 434.1 1.8 48075.2 427 1.7 New York State Cancer Mortality Rate by Gender 1976-1981 1982-1986 1987-1991 1992-1996 1997-2001 2001-2005 Avg. Adj 95% CI Avg. Adj 95% CI Avg. Adj 95% CI Avg. Adj 95% CI Avg. Adj 95% CI Avg. 95% CI Site of Cancer Deaths Rate (+/-) Deaths Rate (+/-) Deaths Rate (+/-) Deaths Rate (+/-) Deaths Rate (+/-) Cases Adj Rate (+/-) Cancer Mortality among Males All Invasive Malignant Tumors 22845 283.1 1.7 19255.4 280.6 1.9 19292.8 275.4 1.8 19163 265 1.7 18350.8 238.6 1.6 17714 215.8 1.4 Cancer Mortality among Females All Invasive Malignant Tumors 21326 182.4 1.1 18480.8 181.9 1.2 18921.6 181.2 1.2 19364.4 179.9 1.1 18839.8 167.3 1.1 18345.4 155.6 1 Orange County Cancer Incidence Rate by Gender 1976-1981 1982-1986 1987-1991 1992-1996 1997-2001 2001-2005 Avg. Adj 95% Avg. Adj 95% Avg. Adj 95% Avg. Adj 95% Avg. Adj 95% Avg. 95% CI Site of Cancer Deaths Rate (+/-) Deaths Rate (+/-) Deaths Rate (+/-) Deaths Rate (+/-) Deaths Rate (+/-) Cases Adj Rate (+/-) Cancer Incidence among Males All Invasive Malignant Tumors 523.8 475.6 19.2 515.6 525 21.3 525.8 502 20.1 703 620.1 21.2 768.2 601.1 19.5 830.2 590.7 18.6 Cancer Incidence among All Invasive Malignant Tumors 498.8 340.8 13.6 504 383 15.2 563.8 395.7 14.7 699.6 457.4 15.2 780.2 472.1 14.9 832.2 468.5 14.3 Orange County Cancer Mortality Rate by Gender 1976-1981 1982-1986 1987-1991 1992-1996 1997-2001 2001-2005 Avg. Adj 95% CI Avg. Adj 95% CI Avg. Adj 95% CI Avg. Adj 95% CI Avg. Adj 95% CI Avg. 95% CI Site of Cancer Deaths Rate (+/-) Deaths Rate (+/-) Deaths Rate (+/-) Deaths Rate (+/-) Deaths Rate (+/-) Cases Adj Rate (+/-) Cancer Mortality among Males All Invasive Malignant Tumors 321.2 298.7 15.4 294.4 312.5 16.8 301.6 302.7 16 316.4 299.9 15.4 291.4 247.5 13.1 299 234.4 12.3 Cancer Mortality among Females All Invasive Malignant Tumors 278.6 190 10.1 273.2 204.8 11 283 197.1 10.3 301.8 195.8 9.9 313.8 186.3 9.3 321.8 179.6 8.9 Rates are per 100,000 persons, age-adjusted to the 2000 US standard population, with 95% confidence intervals. Rates based on fewer than 4 deaths per year are unstable and should be used with caution. Source: Exhibit New 1A. 87 York State Cancer Registry 202

AGE-ADJUSTED CANCER INCIDENCE RATES BY SITE AND GENDER, ORANGE COUNTY, 2001-2005 Cancer Site Oral Cancer and pharynx cancer Colorectal cancer Liver/intrahepatic bile duct cancer Lung and broncus cancer Female breast cancer Prostate cancer Urinary bladder cancer Kidney and renal pelvis cancer Brain and other nervous system cancer Thyroid cancer Non-Hodgkin lymphomas Leukemias *Statistically significant Rates are age-adjusted to 2000 Census. Rate per 100,000 males/females Source: New York State Cancer Registry, 2008 Orange County New York State 30% above NYS 20-29% above NYS Within 20% below & 20% below NYS Incidence Rate* Incidence Rate* Rate Rate above NYS Rate Rate Male Female Male Female Male Female Male Female Male Female Male Female 12.7 4.6 14.5 6.0 x x 66.5 51.9 63.5 47.3 x x 11.5 2.6 10.9 3.5 x x* 91.9 63.0 80.8 53.8 x x 133.5 124.8 x 169.5 166.3 x 50.5 12.1 42.1 11.2 x x 18.3 11.6 19.5 9.5 x* x 8.7 7.0 8.2 5.9 x x 7.1 26.0 5.4 15.0 x x* 25.4 18.3 24.3 17.0 x x 15.0 11.0 16.7 10.1 x x Exhibit 1A.88a 203

DISCHARGE RATE FOR MALIGNANT NEOPLASMS PER 10,000 BY GENDER, ORANGE COUNTY, HUDSON VALLEY REGION, NEW YORK STATE, 2004-2006 Male Female Region Count Rate Count Rate Orange County 3,660 886 5,365 1,027 Hudson Valley Region 33,096 1,042 33,916 1,037 New York State 273,905 1,006 281,080 973 Source: 2004-2006 SPARCS Data from the Health Information Network (HIN) as of August, 2009 Table prepared by SUNY Albany School of Public Health, August, 2009 Exhibit 1A.88b 204

MORTALITY FROM MALIGNANT NEOPLASMS BY ORANGE COUNTY AND UPSTATE NEW YORK, 1998-2006 BY GENDER, RACE, ETHNICITY, AGE GROUPS AND HEALTH PLANNING ZONES Number of Deaths 2004 2005 2006 1998-2000 2001-2003 2004-2006 Number Number Number of Deaths Number Number of Deaths Rate Rate of Deaths Rate of Deaths Rate Rate of Deaths Rate Orange County 599 187.1 574 179.4 554 168.3 1,192 135.9 1,782 191.2 1,727 178.5 Total Upstate NY 23,208 185.1 22,824 180.7 22,744 178.5 60,478 200.5 70,346 167.3 68,776 181.4 Orange Males+ County 296 224.9 275 210.8 272 196.6 573 159.2 841 218.4 843 210.6 Upstate NY 11,517 217.8 11,353 212.9 11,282 209.0 24,839 240.4 34,904 153.0 34,152 213.2 Orange Females+ County 303 164.2 299 159.7 282 148.9 619 121.0 941 174.8 884 157.5 Upstate NY 11,691 163.5 11,471 159.2 11,462 158.2 35,639 174.6 35,442 167.9 34,624 160.3 Race/ Ethnicity White 542 184.8 529 180.0 512 169.8 1,116 133.8 1,647 190.7 1,583 178.2 Black 41 3,247.3 32 3,104.3 36 2,767.8 67 143.5 107 186.7 109 171.3 Other s/n s/n s/n s/n s/n s/n s/n s/n 27 52.0 32 38.4 Hispanic 23 3,055.5 24 3,071.0 s/n s/n 27 73.2 71 122.1 61 94.3 Age* < 5 0 s/n s/n s/n 0 s/n s/n s/n 0 s/n s/n s/n 5-14 s/n s/n s/n s/n 0 s/n s/n s/n s/n s/n s/n s/n 15-24 s/n s/n 0 s/n s/n s/n s/n s/n s/n s/n s/n s/n 25-34 s/n s/n s/n s/n s/n s/n s/n s/n s/n s/n s/n s/n 35-44 s/n s/n s/n s/n s/n s/n 27 15.4 72 40.7 39 22.9 45-54 65 121.6 44 80.6 49 88.0 111 81.2 162 106.2 158 96.5 55-64 85 247.7 90 251.5 110 295.9 220 274.9 329 356.9 285 265.7 65-74 167 888.5 143 753.6 138 715.3 317 577.1 425 767.9 448 785.1 75-84 153 1,219.6 168 1,341.3 153 1,227.8 315 865.0 503 1,340.3 474 1,262.9 85+ 108 2,168.2 108 2,133.5 86 1,661.8 189 1,404.3 272 1,881.1 302 1,984.5 Zones Central 148 187.7 152 195.4 140 182.4 305 148.7 444 199.5 440 180.0 East 171 179.1 156 161.4 154 160.4 337 127.6 521 187.5 481 167.0 Middletown City 65 248.0 65 224.8 45 168.2 117 163.2 149 199.2 175 226.5 Newburgh City 42 191.9 37 173.9 49 232.6 83 137.2 117 180.5 128 199.1 North 61 189.4 43 130.1 48 144.9 113 125.2 191 201.4 152 154.7 Port Jervis City 28 276.9 24 228.1 s/n s/n 51 180.9 85 286.6 71 232.4 West 84 180.9 97 178.0 99 180.1 186 123.1 275 172.4 280 168.9 Rates per 100,000 population Except as noted all mortality rates are age-sex adjusted to the US Census 2000 Population. +Age adjusted mortality rate *Crude mortality rate (i.e., not age or sex adjusted) s/n = Data are unreliable due to small number of cases Populations used in calculating rates are from the Vintage 1990 population with bridged race estimates, Census 2000, and Vintage 2000 with bridged race estimates. Vintage data was downloaded from the National Center for Health Statistics. Population data for gender, racial and ethnic groups for Health Planning Zones was derived from the Census 2000 for these racial groups and interpolated from the Vintage estimates by town. Mortality rates are based on events with known age and gender Data Source: NYS DOH Vital Statistics. Deaths for Orange County residents that were recorded in NYC are not recorded in this analysis. Data analysis and table by the School of Public Health, University at Albany, August, 2009. Exhibit 1A.89a 205

MALIGNANT NEOPLASMS MORTALITY RATES PER 100,000 BY RACE AND ETHNICITY, ORANGE COUNTY, 1998-2006 M O R T A L I T Y R A T E 250.0 200.0 150.0 100.0 50.0 - White Black Other Hispanic Race/ Ethnicity 1998-2000 2001-2003 2004-2006 Except as noted all mortality rates are age-sex adjusted to the US Census 2000 Population. Populations used in calculating rates are from the Vintage 1990 population with bridged race estimates, Census 2000, and Vintage 2000 with bridged race estimates. Vintage data was downloaded from the National Center for Health Statistics. Mortality rates are based on events with known age and gender Data Source: NYS DOH Vital Statistics. Deaths for Orange County residents that were recorded in NYC are not recorded in this analysis. Graph by the School of Public Health, University at Albany, August, 2009. Exhibit 1A.89b 206

MORTALITY RATES FOR MALIGNANT NEOPLASM BY GENDER, ORANGE COUNTY, 1998-2006 M o r t a l i t y R a t e 300.0 250.0 200.0 150.0 100.0 50.0 Orange County Upstate NY Orange County Upstate NY Males+ Females+ 1998 2000 2001 2003 2004 2006 +Age adjusted mortality rate Populations used in calculating rates are from the Vintage 1990 population with bridged race estimates, Census 2000, and Vintage 2000 with bridged race estimates. Vintage data was downloaded from the National Center for Health Statistics. Population data for gender, racial and ethnic groups for Health Planning Zones was derived from the Census 2000 for these racial groups and interpolated from the Vintage estimates by town. Mortality rates are based on events with known age and gender Data Source: NYS DOH Vital Statistics. Graph by the School of Public Health, University at Albany, August, 2009. Deaths for Orange County residents that were recorded in NYC are not recorded in this analysis. Exhibit 1A.89c 207

Region/County LUNG AND BRONCHUS CANCER ANNUAL INCIDENCE AND MORTALITY RATES BY GENDER, ORANGE COUNTY, HUDSON VALLEY REGION AND NYS, 2001-2005 Males Incidence Females Rate per 100,000 Females HP 2010 Target for Mortality: 44.9/100,000 Mortality Males Females Average Rate per Average Rate per Annual 100,000 Annual 100,000 Deaths Males Deaths Females Average Annual Cases Rate per 100,000 Males Average Annual Cases New York State 6,822.60 80.8 6161 53.8 5,081.20 61 4,360 37.5 Hudson Valley Region 765.0 76.9 741.0 57.0 564.0 57.9 513.0 39.0 Orange County 123.6 91.9 108.8 63 90.8 69.1 77.8 44.7 BREAST CANCER ANNUAL INCIDENCE AND MORTALITY RATES BY GENDER ORANGE COUNTY, HUDSON VALLEY REGION AND NYS, 2001-2005 HP 2010 Target for Mortality: 22.3/100,000 Region/County Incidence Females Mortality Females Rate per Average Annual Cases Rate per 100,000 Females Average Annual Deaths 100,000 Females New York State 13,774.60 124.8 2,958 25.5 Hudson Valley Region 1,702 133.3 339.0 25.6 Orange 238.4 133.5 48.2 26.6 CERVICAL CANCER ANNUAL INCIDENCE AND MORTALITY RATES, BY GENDER ORANGE COUNTY, HUDSON VALLEY REGION AND NYS, 2001-2005 HP 2010 Target for Mortality: 2/100,000 Incidence Mortality Region/County Females Females Rate per Average Annual Cases Rate per 100,000 Females Average Annual Deaths 100,000 Females New York State 931.4 8.9 284.4 2.6 Hudson Valley Region 103.0 8.5 29.0 2.3 Orange 19 10.6 5 2.9 Incidence data are provisional, January 2008 Rates are per 100,000 persons, age-adjusted to the 2000 US standard population. *Rates based on fewer than 4 cases or deaths per year are unstable and should be used with caution. Source: New York State Cancer Registry Exhibit 1A.90 208

TRENDS IN MORTALITY RATE FROM LUNG AND BRONCHUS CANCER, ORANGE COUNTY, UPSTATE NEW YORK, 1997-2006 LUNG & BRONCHUS CANCER DEATH RATE PER 100,000 POPULATION Year Single Year Orange County 3-Year Average Orange County Upstate New York 1997 49 59.2 1998 49.7 49.6 59.4 1999 50.2 49.9 59.7 2000 49.8 49 60.1 2001 46.9 47.1 58.7 2002 44.6 45.1 59.6 2003 43.8 46.2 58 2004 50.2 47.1 58.3 2005 47.2 47.2 57.8 2006 44.1 57.8 Source: 2002-2006 Vital Statistics Data as of April, 2008 Exhibit 1A. 91a. 209

TRENDS IN MORTALITY RATE FROM FEMALE BREAST CANCER, ORANGE COUNTY, UPSTATE NEW YORK, 1997-2006 FEMALE BREAST CANCER DEATH RATE PER 100,000 FEMALE POPULATION Year Single Year Orange County 3-Year Average Orange County Upstate New York 1997 30.5 35.4 1998 36.2 32.6 35.9 1999 31 31.7 33.6 2000 28 29 33.7 2001 28.1 26.8 32.6 2002 24.2 24.6 32.2 2003 21.6 26.5 32.2 2004 33.7 27.3 29.8 2005 26.5 26.6 29.4 2006 19.8 28.1 Source: 2002-2006 Vital Statistics Data as of April, 2008 Exhibit 1A. 91b 210

TRENDS IN MORTALITY RATE FROM UTERINE CERVICAL CANCER, ORANGE COUNTY, UPSTATE NEW YORK, 1997-2006 UTERINE CERVICAL CANCER DEATH RATE PER 100,000 FEMALE POPULATION Year Single Year Orange County 3-Year Average Orange County Upstate New York 1997 5.5 3.3 1998 1.8 3.4 2.5 1999 3 2.8 2.9 2000 3.5 2.5 2.6 2001 1.1 2.3 2.5 2002 2.3 2.4 2.7 2003 3.9 2.8 2.5 2004 2.2 3.5 2.4 2005 4.3 2.7 2.5 2006 1.6 2.3 Source: 2002-2006 Vital Statistics Data as of April, 2008 Exhibit 1A. 91c 211

TRENDS IN MORTALITY RATE FROM COLORECTAL CANCER, ORANGE COUNTY, UPSTATE NEW YORK, 1997-2006 COLORECTAL CANCER DEATH RATE PER 100,000 POPULATION Year Single Year Orange County 3-Year Average Orange County Upstate New York 1997 18.2 24.6 1998 19.9 20.1 24.4 1999 22.3 20.3 24.7 2000 18.7 21 24.3 2001 22 19.8 23.2 2002 18.8 20.5 23.3 2003 20.7 19.8 21.3 2004 20 19.8 21.1 2005 18.8 17.1 19.4 2006 12.8 19 Source: 2002-2006 Vital Statistics Data as of April, 2008 Exhibit 1A. 91d 212

TRENDS IN MORTALITY RATE FROM OROPHARYNGEAL CANCER, ORANGE COUNTY, UPSTATE NEW YORK, 1997-2006 LIP, ORAL CAVITY, & PHARYNX CANCER DEATH RATE PER 100,000 POPULATION Year Single Year Orange County 3-Year Average Orange County Upstate New York 1997 2.4 2.8 1998 2.7 2.8 3 1999 3.3 2.6 2.8 2000 1.7 2.5 2.5 2001 2.6 3.1 2.7 2002 5 3 2.5 2003 1.4 2.5 2.5 2004 1.1 1.3 2.8 2005 1.3 1.1 2.4 2006 0.8 2.5 Exhibit 1A. 91e Source: 2002-2006 Vital Statistics Data as of April, 2008 213

COLORECTAL CANCER ANNUAL INCIDENCE AND MORTALITY RATES BY GENDER, ORANGE COUNTY, HUDSON VALLEY REGION AND NYS, 2001-2005 Region/County Average Annual Cases Males Females Males Rate per 100,000 Males Average Annual Cases Rate per 100,000 Females Average Annual Deaths Rate per 100,000 Males Average Annual Deaths Rate per 100,000 Females New York State 5,330.20 63.5 5573 47.3 1,866.60 23 2,009.20 16.4 Hudson Valley Region 611.0 61.40 624.0 46.70 211.0 22.20 233.0 16.7 Orange 90.2 66.5 92.6 51.9 33.8 27.2 38.6 21 PROSTATE CANCER ANNUAL INCIDENCE AND MORTALITY RATES BY GENDER, ORANGE COUNTY, HUDSON VALLEY REGION AND NYS, 2001-2005 HP 2010 Target for Mortality: 28.8/100,000 Incidence Mortality Region/County Males Males Average Annual Cases Rate per 100,000 Males Average Annual Deaths Rate per 100,000 Males New York State 14,354.80 166.3 1,938.40 25.7 Hudson Valley Region 1,746 168.5 220.0 25.80 Orange 237.8 169.5 29.8 27.3 OROPHARYNGEAL CANCER: ANNUAL INCIDENCE AND MORTALITY RATES BY GENDER, ORANGE COUNTY, HUDSON VALLEY REGION AND NYS, 2001-2005 Region/County Average Annual Cases Rate per 100,000 Males Average Annual Cases Rate per 100,000 Females Average Annual Deaths Rate per 100,000 Males Average Annual Deaths Rate per 100,000 Females New York State 1,303.40 14.5 669.8 6 318.4 3.6 161.6 1.4 Hudson Valley Region 143.0 13.2 75.0 5.8 32.0 3.2 18.0 1.3 Orange 20.6 12.7 8 4.6 5.2 3.2 3 1.7 THYROID CANCER: ANNUAL INCIDENCE AND MORTALITY RATES BY GENDER, ORANGE COUNTY, HUDSON VALLEY REGION AND NYS, 2001-2005 Region/County Average Annual Cases Males Rate per 100,000 Males Incidence Incidence Average Annual Cases Females Rate per 100,000 Females Average Annual Deaths Rate per 100,000 Males Average Annual Deaths Rate per 100,000 Females New York State 502 5.4 1,549.40 15 36.6 0.4 58.4 0.5 Hudson Valley Region 78.0 7.0 240.0 20.3 5.0 0.5 7.0 0.5 Orange 12.2 7.1 46.8 26 0.4 0.4 1 0.6 Incidence data are provisional, January 2008 Rates are per 100,000 persons, age-adjusted to the 2000 US standard population. Rates based on fewer than 4 cases or deaths per year are unstable and shoul d be used with caution. Source: New York State Cancer Registry Males HP 2010 Target for Mortality: 13.9/100,000 Mortality Females HP 2010 Target for Mortality: 2.7/100,000 Mortality Females Incidence Mortality Males Females Males Females Exhibit 1A. 92 214

MORTALITY FROM DIABETES BY GENDER, RACE, ETHNICITY, AGE GROUPS AND HEALTH PLANNING ZONES, ORANGE COUNTY AND UPSTATE NEW YORK, 1998-2006 Number of Deaths 2004 2005 2006 1998-2000 2001-2003 2004-2006 Number Number of Deaths Number Number Number of Deaths Rate of Deaths Rate Rate of Deaths Rate of Deaths Rate Rate Orange County 62 19.5 65 19.7 61 18.5 113 13.0 144 15.5 188 19.2 Total Upstate NY 2,201 17.5 2,278 17.9 2,158 16.9 6,243 17.5 6,720 16.2 6,637 17.5 Orange Males+ County 36 25.9 38 27.1 32 22.4 48 14.2 74 19.2 106 25.1 Upstate NY 1,096 20.7 1,157 21.8 1,145 21.2 2,959 20.1 3,196 14.5 3,398 21.2 Orange Females+ County 26 14.2 27 14.6 29 15.1 65 12.6 70 13.1 82 14.7 Upstate NY 1,105 14.9 1,121 15.0 1,013 13.6 3,284 15.5 3,524 16.0 3,239 14.5 Race/ Ethnicity White 55 18.5 51 16.9 45 14.8 105 13.1 127 14.7 151 16.8 Black s/n s/n s/n s/n s/n s/n s/n s/n s/n s/n 29 45.0 Other s/n s/n s/n s/n s/n s/n 0 s/n s/n s/n s/n s/n Hispanic s/n s/n s/n s/n s/n s/n s/n s/n s/n s/n s/n s/n Age* < 5 0 s/n 0 s/n 0 s/n 0 s/n 0 s/n 0 s/n 5-14 0 s/n 0 s/n 0 s/n 0 s/n 0 s/n 0 s/n 15-24 0 s/n 0 s/n 0 s/n s/n s/n s/n s/n 0 s/n 25-34 0 s/n 0 s/n 0 s/n s/n s/n s/n s/n 0 s/n 35-44 s/n s/n 0 s/n s/n s/n s/n s/n s/n s/n s/n s/n 45-54 s/n s/n s/n s/n s/n s/n s/n s/n s/n s/n s/n s/n 55-64 s/n s/n s/n s/n s/n s/n s/n s/n 25 27.1 42 39.1 65-74 20 106.1 s/n s/n 21 108.8 30 54.6 34 61.4 56 98.1 75-84 s/n s/n s/n s/n s/n s/n 34 93.4 42 111.9 41 109.2 85+ s/n s/n s/n s/n s/n s/n 26 193.2 25 172.9 36 236.6 Zones Central s/n s/n s/n s/n s/n s/n 23 13.1 32 14.2 46 19.4 East s/n s/n s/n s/n s/n s/n 20 11.1 44 16.1 47 36.0 Middletown City s/n s/n s/n s/n s/n s/n s/n s/n s/n s/n 27 31.5 Newburgh City s/n s/n s/n s/n s/n s/n s/n s/n s/n s/n s/n s/n North s/n s/n s/n s/n s/n s/n s/n s/n s/n s/n s/n s/n Port Jervis City s/n s/n s/n s/n s/n s/n s/n s/n s/n s/n s/n s/n West s/n s/n s/n s/n s/n s/n s/n s/n s/n s/n s/n s/n Rates per 100,000 population Except as noted all mortality rates are age-sex adjusted to the US Census 2000 Population. +Age adjusted mortality rate *Crude mortality rate (i.e., not age or sex adjusted) s/n = Data are unreliable due to small number of cases Populations used in calculating rates are from the Vintage 1990 population with bridged race estimates, Census 2000, and Vintage 2000 with bridged race estimates. Vintage data was downloaded from the National Center for Health Statistics. Population data for gender, racial and ethnic groups for Health Planning Zones was derived from the Census 2000 for these racial groups and interpolated from the Vintage estimates by town. Mortality rates are based on events with known age and gender Data Source: NYS DOH Vital Statistics. Deaths for Orange County residents that were recorded in NYC are not recorded in this analysis. Data analysis and table by the School of Public Health, University at Albany, August, 2009. Exhibit 1A.93a 215

MORTALITY FROM DIABETES, PER 100,000, BY GENDER, ORANGE COUNTY AND UPSTATE NY, 1998-2006 30.0 25.0 Mortality Rate 20.0 15.0 10.0 5.0 Orange County Upstate NY Orange County Upstate NY Males+ Females+ 1998 2000 2001 2003 2004 2006 Data recorded in NYC are not included in this analysis. Graph prepared by SUNY Albany School of Public Health, August, 2009 +Age adjusted mortality rate Data Source: NYS DOH Vital Statistics Exhibit 1A.93b 216

DISCHARGE RATE FOR DIABETES PER 10,000 BY GENDER, ORANGE COUNTY, HUDSON VALLEY REGION, NEW YORK STATE, 2004-2006 Male Female Region Count Rate Count Rate Orange County 1,053 20 762 14.59 Hudson Valley Region 5,427 17 4,635 14.17 New York State 61,432 23 57,873 20.03 Rates generated from low numerator values should be interpreted with caution. Source: 2004-2006 SPARCS Data from the Health Information Network (HIN) as of August, 2009 Table prepared by SUNY Albany School of Public Health, August, 2009 Exhibit 1A.94 217

MORTALITY FROM COPD/CLRD** BY GENDER, RACE, ETHNICITY, AGE GROUPS AND HEALTH PLANNING ZONES, ORANGE COUNTY AND UPSTATE NEW YORK, 1998-2006 Number of Deaths 2004 2005 2006 1998-2000 2001-2003 2004-2006 Number Number Number Number of Deaths Rate Number of Deaths Rate of Deaths Rate of Deaths Rate of Deaths Rate Rate Orange County 173 56.3 161 50.9 124 38.8 277 32.3 483 53.7 458 48.6 Total Upstate NY 5,043 39.9 5,187 40.9 4,849 37.9 15,209 42.3 15,438 37.6 15,079 39.6 Orange Males+ County 78 64.8 74 60.1 68 55.7 115 35.4 219 62.9 220 60.1 Upstate NY 2,277 44.8 2,318 45.3 2,200 42.5 7,188 50.4 7,017 32.8 6,795 44.2 Orange Females+ County 95 52.2 87 45.9 56 28.3 162 30.6 264 47.7 238 42.1 Upstate NY 2,766 36.8 2,869 38.0 2,649 34.8 8,021 37.0 8,421 37.6 8,284 36.6 Race/ Ethnicity White 165 57.7 152 51.5 112 37.6 265 33.2 453 53.6 429 48.9 Black s/n s/n s/n s/n s/n s/n s/n s/n 23 52.6 21 36.5 Other s/n s/n s/n s/n s/n s/n 0 s/n s/n s/n s/n s/n Hispanic s/n s/n s/n s/n s/n s/n s/n s/n s/n s/n s/n s/n Age* < 5 0 s/n 0 s/n 0 s/n 0 s/n 0 s/n 0 s/n 5-14 0 s/n 0 s/n 0 s/n s/n s/n 0 s/n 0 s/n 15-24 0 s/n 0 s/n 0 s/n 0 s/n s/n s/n 0 s/n 25-34 s/n s/n 0 s/n 0 s/n 0 s/n 0 s/n s/n s/n 35-44 s/n s/n s/n s/n s/n s/n s/n s/n s/n s/n s/n s/n 45-54 s/n s/n s/n s/n s/n s/n s/n s/n s/n s/n 22 13.4 55-64 s/n s/n s/n s/n s/n s/n 25 31.2 52 56.0 39 36.5 65-74 45 239.4 36 189.7 20 103.6 62 112.9 101 182.5 101 176.9 75-84 60 478.3 52 415.7 44 353.1 107 293.8 192 511.6 156 415.7 85+ 46 9,235.0 47 928.5 39 753.6 72 535.0 122 843.7 132 867.4 Zones Central 40 52.4 45 60.7 32 39.8 81 41.7 117 55.2 117 50.8 East 40 42.5 38 51.6 25 26.4 44 17.1 130 48.3 103 36.3 Middletown City s/n s/n s/n s/n s/n s/n 31 40.5 45 58.4 41 51.9 Newburgh City s/n s/n s/n s/n s/n s/n s/n s/n 39 59.6 28 43.8 North 29 93.1 s/n s/n s/n s/n 24 27.7 69 76.8 63 65.1 Port Jervis City s/n s/n s/n s/n s/n s/n s/n 56.6 s/n s/n 32 96.0 West 23 41.6 27 29.7 s/n s/n 63 48.2 64 46.0 74 49.4 Rates per 100,000 population Except as noted all mortality rates are age-sex adjusted to the US Census 2000 Population. +Age adjusted mortality rate *Crude mortality rate (i.e., not age or sex adjusted) **COPD=Chronic Obstructive Pulmonary Disease, CLRD=Chronic Lower Respiratory Disease s/n = Data are unreliable due to small number of cases Populations used in calculating rates are from the Vintage 1990 population with bridged race estimates, Census 2000, and Vintage 2000 with bridged race estimates. Vintage data was downloaded from the National Center for Health Statistics. Population data for gender, racial and ethnic groups for Health Planning Zones was derived from the Census 2000 for these racial groups and interpolated from the Vintage estimates by town. Mortality rates are based on events with known age and gender Data Source: NYS DOH Vital Statistics. Deaths for Orange County residents that were recorded in NYC are not recorded in this analysis. Data analysis and table by the School of Public Health, University at Albany, August, 2009. Exhibit 1A.95a 218

MORTALITY FROM COPD/CLRD, BY GENDER, PER 100,000, ORANGE COUNTY AND UPSTATE NEW YORK, 1998-2006 M O R T A L I T Y R A T E 70.0 60.0 50.0 40.0 30.0 20.0 10.0 Orange County Upstate NY Orange County Upstate NY Males+ Females+ 1998 2000 2001 2003 2004 2006 **COPD=Chronic Obstructive Pulmonary Disease, CLRD=Chronic Lower Respiratory Disease Data recorded in NYC are not included in this analysis. Graph prepared by SUNY Albany School of Public Health, August, 2009 +Age adjusted mortality rate Data Source: NYS DOH Vital Statistics Exhibit 1A.95b 219

DISCHARGE RATE FOR CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD) PER 10,000 BY GENDER, ORANGE COUNTY, HUDSON VALLEY REGION, NEW YORK STATE, 2004-2006 Male Female Region Count Rate Count Rate Orange County 1,547 29 2,253 43.15 Hudson Valley Region 7,908 25 11,429 34.93 New York State 92,441 34 127,023 43.96 Rates generated from low numerator values should be interpreted with caution. Source: 2004-2006 SPARCS Data from the Health Information Network (HIN) as of August, 2009 Table prepared by SUNY Albany School of Public Health, August, 2009 Exhibit 1A.96 220

TRENDS IN ASTHMA MORTALITY, TEN YEAR TIME TREND ORANGE COUNTY, UPSTATE NEW YORK, 1997-2006 DEATH AND DEATH RATES OF ASTHMA PER 1,000,000 Year Single Year Orange County 3-Year Average Orange County Upstate New York 1997 12.2 13 1998 21.1 20 13.1 1999 26.7 21.7 12.5 2000 17.5 18.5 11.1 2001 11.4 13.3 11.6 2002 11.2 14 11.4 2003 19.3 15.6 11.9 2004 16.2 18.1 10 2005 18.8 17 10.1 2006 15.9 8.4 DEATH AND DEATH RATES OF ASTHMA PER 1,000,000 Deaths Population Crude Adjusted Region/County 2004 2005 2006 Total 2005 Rate Rate Orange 6 7 6 19 372,893 17 18.1 Hudson Valley Region 24 32 19 75 2,261,204 11.1 10.5 New York State 290 291 241 822 19,254,630 14.2 13.4 Adjusted rates are age-adjusted to the 2000 United States Population. Rates per 1,000,000 population Source: 2004-2006 Vital Statistics Data as of March, 2008 Exhibit 1A. 97 221

MORTALITY FROM CIRRHOSIS OF THE LIVER BY GENDER, RACE, ETHNICITY, AGE GROUPS AND HEALTH PLANNING ZONES, ORANGE COUNTY AND UPSTATE NEW YORK, 1998-2006 Number of Deaths 2004 2005 2006 1998-2000 2001-2003 2004-2006 Number Number of Deaths Number Number Number of Deaths Rate of Deaths Rate Rate of Deaths Rate of Deaths Rate Rate Orange County 29 8.6 24 7.0 26 7.1 47 5.1 80 7.9 79 7.6 Total Upstate NY 792 6.4 775 6.2 767 6.1 2,630 7.5 2,612 6.3 2,334 6.2 Orange Males+ County s/n s/n s/n s/n s/n s/n 34 7.9 54 11.0 48 9.1 Upstate NY 491 8.8 492 8.6 490 8.4 1,680 10.7 1,587 7.2 1,473 8.6 Orange Females+ County s/n s/n s/n s/n s/n s/n s/n s/n 26 4.9 31 6.0 Upstate NY 301 4.4 283 4.1 277 4.0 950 4.8 1,025 5.1 861 4.2 Race/ Ethnicity White 27 9.5 22 7.8 22 7.9 41 5.0 76 8.2 71 7.6 Black s/n s/n 0 s/n s/n s/n s/n s/n s/n s/n 4 s/n Other s/n s/n s/n s/n 0 s/n s/n s/n s/n s/n 3 s/n Hispanic s/n s/n s/n s/n s/n s/n s/n s/n s/n s/n 9 s/n Age* < 5 0 s/n 0 s/n 0 s/n 0 s/n 0 s/n 0 s/n 5-14 0 s/n 0 s/n 0 s/n 0 s/n 0 s/n 0 s/n 15-24 0 s/n 0 s/n 0 s/n 0 s/n 0 s/n 0 s/n 25-34 0 s/n 0 s/n s/n s/n s/n s/n 0 s/n s/n s/n 35-44 s/n s/n s/n s/n s/n s/n s/n s/n s/n s/n s/n s/n 45-54 s/n s/n s/n s/n s/n s/n s/n s/n 29 19.0 21 12.8 55-64 s/n s/n s/n s/n s/n s/n s/n s/n s/n s/n s/n s/n 65-74 s/n s/n s/n s/n s/n s/n s/n s/n s/n s/n 20 35.0 75-84 s/n s/n s/n s/n s/n s/n s/n s/n s/n s/n s/n s/n 85+ s/n s/n 0 s/n 0 s/n s/n s/n s/n s/n s/n s/n Zones Central s/n s/n s/n s/n s/n s/n s/n s/n 23 10.8 s/n s/n East s/n s/n s/n s/n 0 s/n s/n s/n s/n s/n 22 7.3 Middletown City s/n s/n s/n s/n s/n s/n s/n s/n s/n s/n s/n s/n Newburgh City s/n s/n s/n s/n s/n s/n s/n s/n s/n s/n s/n s/n North s/n s/n s/n s/n s/n s/n s/n s/n s/n s/n s/n s/n East 0 s/n 0 s/n 0 s/n s/n s/n s/n s/n 0 s/n West s/n s/n s/n s/n s/n s/n s/n s/n s/n s/n s/n s/n Rates per 100,000 population Except as noted all mortality rates are age-sex adjusted to the US Census 2000 Population. +Age adjusted mortality rate *Crude mortality rate (i.e., not age or sex adjusted) **COPD=Chronic Obstructive Pulmonary Disease, CLRD=Chronic Lower Respiratory Disease s/n = Data are unreliable due to small number of cases Populations used in calculating rates are from the Vintage 1990 population with bridged race estimates, Census 2000, and Vintage 2000 with bridged race estimates. Vintage data was downloaded from the National Center for Health Statistics. Population data for gender, racial and ethnic groups for Health Planning Zones was derived from the Census 2000 for these racial groups and interpolated from the Vintage estimates by town. Mortality rates are based on events with known age and gender Data Source: NYS DOH Vital Statistics. Deaths for Orange County residents that were recorded in NYC are not recorded in this analysis. Data analysis and table by the School of Public Health, University at Albany, August, 2009. Exhibit 1A.98a 222

MORTALITY FROM CIRRHOSIS OF THE LIVER, PER 100,000, BY GENDER, ORANGE COUNTY AND UPSTATE NEW YORK, 1998-2006 M O R T A L I T Y 12.0 10.0 8.0 6.0 4.0 2.0 R Orange County Upstate NY Orange County Upstate NY A Males+ Females+ T E 1998 2000 2001 2003 2004 2006 Data recorded in NYC are not included in this analysis. Graph prepared by SUNY Albany School of Public Health, August, 2009 +Age adjusted mortality rate Data Source: NYS DOH Vital Statistics Exhibit 1A.98b 223

DISCHARGE RATE FOR CIRRHOSIS OF THE LIVER PER 10,000, BY GENDER, ORANGE COUNTY, HUDSON VALLEY REGION, NEW YORK STATE, 2004-2006 Male Female Region Count Rate Count Rate Orange County 265 5 109 2.09 Hudson Valley Region 1,366 4 673 2.06 New York State 13,005 5 6,972 2.41 Rates generated from low numerator values should be interpreted with caution. Source: 2004-2006 SPARCS Data from the Health Information Network (HIN) as of August, 2009 Table prepared by SUNY Albany School of Public Health, August, 2009 Exhibit 1A.99 224

Hospital/Medical Center Services in Orange County New York, 2009 Exhibit 1B.1 Bon Secours Charity Health System Bon Secours Community Hospital -Port Jervis St. Anthony Community Hospital - Warwick Orange Regional Medical Center Goshen Campus Middletown Campus St. Luke s Cornwall Hospital Cornwall Acute/Chronic Renal Dialysis x x x x x Alcohol Detoxification/Rehabilitation x x x Alcohol Rehabilitation O/P* x x Newburgh Keller Army Hospital US Military Academy at West Point Ambulatory Surgery x x x x x x x Asthma Management O/P x x x x x x x Angioplasty x x x Audiology O/P x x x x x Bariatric Surgery x x x Behavioral Health Unit/Center x x x Birthing Center x x x x x Bone Marrow Transplant Burn Center Cancer Screening & Detection x x x x x x x Cardiac Catheterization (Ped) (Adult) x x x CT Scanner x x x x x x x Cardiac Rehabilitation x x x Clinical Laboratory Service x x x x x x x Cystoscopy x x x x x x Dental O/P Designated AIDS Center x Designated Trauma Center Diabetes Treatment Center O/P x x x x x Diagnostic/Therapeutic Radiology x x x x x x x Drug Rehabilitation O/P x x Electrocardiology x x x x x Emergency Department x x x x x x x Family Planning O/P x x Health Education x x x x x x x HIV/AIDS Medical Management O/P x Home Dialysis Training x x x Home Health Care x x x Integrated Medicine Intensive Care Unit/Cardiac Care Unit x x x x x x Exhibit 1B.1 225

Hospital/Medical Center Services in Orange County New York, 2009 Exhibit 1B.1 (continued) Bon Secours Charity Health System Bon Secours Community Hospital -Port Jervis St. Anthony Community Hospital - Warwick Orange Regional Medical Center Goshen Campus Middletown Campus St. Luke s Cornwall Hospital Cornwall Newburgh Keller Army Hospital US Military Academy at West Point Laboratory Services O/P x x x x x x x Labor & Delivery (Maternity) x x x x x Linear Accelerator x x x Lithotripter x x x x Long Term Home Health Care x x Magnetic Resonance Imaging x x x x x x Medical Rehabilitation x x x Methadone Maintenance O/P Neonatal Intensive Care Unit Nuclear Medicine Diagnostic/Therapeutic x x x x x x Nutrition Counseling O/P x x x x x x x Medical/Health Information Line x x x x x x x Occupation Therapy O/P x x x x Open Heart Surgery (Ped) (Adult) Oncology O/P x x x x Pain Management O/P x x x x Palliative Care/Hospice x x Part Time Clinics PCAP Provider PET Scanner x x x x Physical Med & Rehab O/P x x x x x x Physical Therapy O/P x x x x x x x Podiatry O/P Primary Medical Care O/P (Ped) (Adult) x x x x x x Psychiatric Services x x x x x Psychiatric/Mental Health Services O/P x x x x Ultrasound x x x x x x x Social Work Service O/P x x x x Speech Language Pathology O/P x x x x x Substance Abuse Counseling O/P x x x x x x x x Exhibit 1B.1 226

Hospital/Medical Center Services in Orange County New York, 2009 Exhibit 1B.1 (Continued) Bon Secours Charity Health System Bon Secours Community Hospital -Port Jervis St. Anthony Community Hospital - Warwick Orange Regional Medical Center Goshen Campus Middletown Campus St. Luke s Cornwall Hospital Cornwall Newbur gh Keller Army Hospital US Military Academy at West Point Support Groups x x x x x x x Sexually Transmitted Disease Screening and Treatment O/P x x x x x x Vocational Rehabilitation Wound Care Center x x x x Additional Services: Assisted Living Adult Day Medical Program x x Bone Densitometry x x x x x Cardiology, GI & Orthopedic Clinic x x-ortho Center for Sleep & Breathing Disorders x x Mammography x x x x x x x PET/CT x x x x x Sexual Assault Nurse Examiner Pgm. x Vascular Lab x x x * O/P = outpatient services Sources: New York State Department of Health, Northern Metropolitan Hospital Association & Individual Hospitals/Medical Centers Exhibit 1B.1 227

Hospital/Medical Center Service Statistics Orange County, 2008 Exhibit 1B.2 Bon Secours Charity Health System Bon Secours Community Hospital-Port Jervis St. Anthony Community Hospital Warwick Orange Regional Medical Center Goshen Campus and Middletown Campuses Combined St. Luke s Cornwall Hospital Keller Army Hospital Cornwall Newburgh US Military Academy at West Point TOTAL NUMBER OF CERTIFIED BEDS 141 73 450 125 242 26 Medical-Surgical 70 52 347 89 172 20 Intensive Care 10 4 36 10 10 Neonatal Intermediate Care 10 Coronary Care 4 6 8 Pediatric 8 5 29 4 19 Psychiatric 20 40 22 Physical Medicine & Rehabilitation 17 Coma Recovery 2 Alcohol Detoxification 10 Alcohol Rehabilitation 15 Trauma Brain Injury 10 Maternity (excluding bassinets) 8 8 34 23 6 PATIENT SERVICES Patient Days 27,254 13,997 108,607 18,746 47,782 2,478 Discharges 4,946 3,455 21,378 3,535 10,255 1,107 Outpatient Visits 52,711 37,937 765,086 168,140 98,849 Emergency Department Visits 24,583 12,662 58,513 16,679 33,859 9,559 TOTAL NUMBER OF BIRTHS 273 555 1,697 1,103 161 Sources: New York State Department of Health, Northern Metropolitan Hospital Association & Individual Hospitals/Medical Centers Exhibit 1B.2 228

Community Health Center Services in Orange County NY, 2009 Exhibit 1B.3 Bon Secours Charity Health System McAuley Primary Care Center Port Jervis Ezras Choilim Health Care, Inc. Greater Hudson Valley Health Center Kiryas Joel Newburgh Community Health Center - Walden Hudson River Community Health Migrant Health Center- Goshen Middletown Community Health Center Middletown United Community Health Center - Pine Bush General Primary Care (Pediatric, Adolescent, Adult) x x x x x x x Emergency Medical Services/Urgent Medical Care x Family Planning x x x x x x HIV Counseling & Testing x x x x x x Gynecology x x x x x x x Obstetrics x x x x x x Dental Services x x x x x x Mental Health Treatment & Counseling x Substance Abuse Treatment & Counseling x Nutrition Counseling x x x x x x WIC x x x Case Management x x x x x Health Education & Outreach x x x x x x x x (Cervical Mammography & Cancer Cervical Cancer Screening Screening only) x x x x x x Allergy & Immunology x x Endocrinology x x x x Podiatry x x x x x Pharmacy Services x x Laboratory Services x x x x x x Evening hours x x x x x x x Weekend hours x x x x Sources: UDS Reports and information provided by individual Community Health Centers. Exhibit 1B.3 229

Hospital/Medical Center and Community Health Center Locations (C) in Orange County, New York, 2009 1 2 3 4 5 6 7 Deerpark Port Jervis 1 Bon Secours Arden Hill Horton St. Luke s Cornwall C Keller St. Anthony's Greenville Mount Hope Minisink Wallkill Middletown Wawayanda Goshen Exhibit 1B.4 C 2 Warwick Crawford 7 3 C C Exhibit 1B 4 Hamptonburgh Chester C Montgomery Blooming Grove C Monroe Tuxedo Woodbury Town of Newburgh City of Newburgh New Windsor Cornwall 5 C 4 Highlands 230 6

ORANGE COUNTY, NEW YORK CERTIFIED HOME HEALTH AGENCIES ORANGE COUNTY DEPARTMENT OF HEALTH Certified Home Health Agency; Long Term Home Health Care Program 124 Main St, Goshen, NY 10924 845-291-2332 33 Fulton St. Middletown, NY 10940 845-346-1113 141 Broadway Newburgh, NY 12550 845-568-5333 www.orangecountygov.com GOOD SAMARITAN HOSPITAL HOME CARE Certified Home Health Agency; Long Term Home Health Care Program; AIDS Home Care Program 15 Matthews Avenue Goshen, NY 10924 845-294-2011 www.goodsamhosp.org ELANT Long Term Home Health Care Program 46 Harriman Drive Goshen, NY 10924 845-291-3700 www.elant.org WILLCARE Certified Home Health Agency 700 Corporate Blvd Newburgh, NY 12550 845-561-3655 www.willcare.com Exhibit 1B5 231

ORANGE COUNTY, NEW YORK LICENSED HOME HEALTH AGENCIES ANYTIME HOME CARE Licensed Home Care Agency 410 Gidney Way, Newburgh, NY 12550 845-565-1212 9 ½ Dolson Avenue, Middletown, NY 10940 845-344-4222 www.anytimehomecare.com J AND D ULTRACARE CORPORATION Licensed Home Care Agency focus is primarily pediatrics 99 Washington Avenue Suffern, NY 10901 845-357-4500 or 800-257-3130 www.jdultracare.com UNLIMITED CARE, INC. Licensed Home Care Agency 453 Route 211 East Suite 304 Middletown, NY 10940 845-342-2220 www.unlimitedcareinc.com WELLNESS HOME CARE Licensed Home Care Agency 252 Main Street Goshen, NY 10924 845-294-8364 www.wellnesshomecare.com WILLCARE, INC. Licensed Home Care Agency 726 East Main Street, Suite 501 Middletown, NY 10940 845-342-1661 www.willcare.com Exhibit 1B5 232

ORANGE COUNTY, NEW YORK NURSING HOMES CAMPBELL HALL REHAB CENTER 23 Kiernan Road Campbell Hall, NY 10916 Beds - 134 845-294-8154 ELANT at GOSHEN, INC. 46 Harriman Drive Goshen, NY 10924 Beds 120 845-291-3700 www.elant.org ELANT at NEWBURGH 172 Meadow Hill Road Newburgh, NY 12550 Beds 190 845-564-1700 www.elant.org GLEN ARDEN INC. 46 Harriman Drive Goshen, NY 10924 Beds - 40 845-291-7800 www.elant.org MONTGOMERY NURSING HOME 2817 Albany Post Road, Box 158 Montgomery, NY 12549 Beds 100 845-457-3155 PARK MANOR REHAB AND HEALTH CARE CENTER 121 Dunning Road Middletown, NY 10940 Beds 250 845-343-0801 www.parkmanorrehab.com SCHERVIER PAVILION 22 Van Duzer Place Warwick, NY 10990 Beds 120 845-987-5717 www.stanthonycommunityhosp.org ST.JOSEPH S PLACE 160 East Main Street Port Jervis, NY 12771 Beds 46 845-856-5351 www.bonsecourscommunityhosp.org ST TERESA S NURSING AND REHABILITATION CENTER 120 Highland Avenue Middletown, NY 10940 Beds 98 845-342-1033 THE VALLEY VIEW CENTER FOR NURSING CARE AND REHABILITATION Glenmere Cove Road, Box 59 Goshen, NY 10924 Beds 520 845-291-4740 www.orangecountygov.com Source: www.health.state.ny.us Exhibit 1B6 233

NEW YORK STATE DEPARTMENT OF HEALTH OFFICE OF MANAGED CARE COUNTY DIRECTORY OF MANAGED CARE PLANS, 2009 Orange County Commercial Participating Programs Medicaid Child Health Plus Plans Aetna Health Inc. YES *** *** *** Affinity Health Plan, Inc. *** YES YES YES Capital District Physicians' Health Plan YES *** YES *** Cigna Healthcare of New York, Inc. YES *** *** *** ConnectiCare of New York, Inc. YES *** *** *** Empire HealthChoice HMO, Inc. YES *** YES *** GHI HMO Select, Inc. YES *** YES YES Health Insurance Plan of Greater New York, Inc. YES *** *** *** Health Net of New York, Inc. YES *** *** *** Horizon HealthCare of New York, Inc. YES *** *** *** Hudson Health Plan, Inc. *** YES YES YES MVP Health Plan, Inc. YES *** *** *** New York State Catholic Health Plan, Inc. *** *** YES *** Oxford Health Plans of New York Inc. YES *** *** *** UnitedHealthcare of New York, Inc. YES *** *** *** WellCare of New York, Inc. *** YES YES *** Source: New York State Department of Health Medicaid Publications Family Health Plus Exhibit 1B.7 234

EXPANDED BRFSS ACCESS TO CARE RESULTS, ORANGE COUNTY, HUDSON VALLEY REGION, AND NYS, 2003 Reported Having a Routine Physical Exam in Past Two Years Locality n¹ Yes n No C.I.³ %² % Dutchess, Putnam 551 89.2 70 10.8 2.7 Orange 570 89 64 11 2.8 Rockland 551 85.7 75 14.3 3.4 Sullivan, Ulster 571 89.5 68 10.5 2.7 Westchester 563 91.3 53 8.7 2.6 Hudson Valley Region 2,806 89.5 330 10.5 Time in Past 12 Months When Needed Medical Care but Could Not Get It New York State Demographic n¹ Yes n No C.I.³ Groups %² % Total 1,435 7.6 22,723 92.4 0.7 Gender Male 466 6.3 9,012 93.7 1 Female 969 8.7 13,711 91.3 0.9 Age 18-24 169 10.9 1,456 89.1 2.8 25-34 314 11.7 3,327 88.3 2 35-44 378 8.8 4,740 91.2 1.5 45-54 319 7 4,433 93 1.5 55-64 153 4.9 3,364 95.1 1.4 ³65 89 1.6 5,074 98.4 0.6 Race/Ethnicity White 956 4.2 18,920 95.8 0.5 Black 120 7.6 1,202 92.4 1.9 Hispanic 215 18.6 1,197 81.4 3 Other 115 10.6 1,099 89.4 3.1 Education <High School 252 14.8 2,125 85.2 3.1 High School 459 8 7,248 92 1.4 >High School 716 5.9 13,268 94.1 0.7 Household Income <$10,000 192 18.2 1,077 81.8 4.7 $10,000-24,999 597 15 4,663 85 2.1 $25,000-49,999 332 6.4 6,343 93.6 1.2 ³$50,000 154 2.4 7,622 97.6 0.6 Time in Past 12 Months when Needed Medical Care but Could Not Get It Locality n¹ Yes n No C.I.³ %² % Dutchess, Putnam 31 4.1 596 95.9 1.6 Orange 43 7.9 593 92.1 2.9 Rockland 37 6.5 596 93.5 2.5 Sullivan, Ulster 55 8.9 586 91.1 2.7 Westchester 41 7.4 577 92.6 2.4 Hudson Valley Region 207 6.6 2,948 93.4 ¹ Percents based on row denominators of less than 50 are unstable and should be used with caution ²Weighted Percent ³95% Confidence Interval 4 Significant difference from Orange County Exhibit 1B. 8 235

EXPANDED BRFSS RESULTS FOR CORE MODULES, ORANGE COUNTY, HUDSON VALLEY REGION AND REST OF NYS, 2003 Self-Rated Health Status Demographic Fair or Poor Good to Excellent C.I.³ Groups n¹ %² n % New York State 3,881 16.9 20,188 83.1 0.9 Orange 96 13.6 541 86.4 3 Fair or Poor Good to Excellent C.I.³ Locality n¹ %² n % Dutchess, Putnam 71 12.0 554 88.0 3.1 Orange 96 13.6 541 86.4 3 Rockland 69 11.4 559 88.6 3 Sullivan, Ulster 100 13.4 541 86.6 2.9 Westchester 80 12.8 535 87.2 3 Hudson Valley Region 416 13.2 2730 86.8 Participated in Leisure-Time Physical Activity or Exercise During the Past 30 Days Demographic Yes No C.I.³ Groups n¹ %² n % New York State 18,057 74.6 6115 25.4 1 Orange 460 73.5 176 26.5 4.1 Yes No C.I.³ Locality n¹ %² n % Dutchess, Putnam 496 78.8 131 21.2 3.8 Orange 460 73.5 176 26.5 4.1 Rockland 456 72.0 179 28.0 4 Sullivan, Ulster 488 78.9 155 21.1 3.4 Westchester 481 80.1 139 19.9 3.6 Hudson Valley Region 2,381 75.3 780 24.7 ¹ Percents based on row denominators of less than 50 are unstable and should be used with caution ²Weighted Percent ³95% Confidence Interval # These Counties had significantly different variables from Orange County Exhibit 1C.1 236

EXPANDED BRFSS RESULTS FOR CORE MODULES, ORANGE COUNTY, HUDSON VALLEY REGION AND REST OF NYS, 2003 Physician-Diagnosed Diabetes 2 Demographic Yes No C.I.³ Groups n¹ %² n % New York State 1,874 7.2 22,311 92.8 0.6 Orange 44 6.1 594 93.9 1.9 Yes No C.I.³ Locality n¹ %² n % Dutchess, Putnam 46 7.5 581 92.5 2.3 Orange 44 6.1 594 93.9 1.9 Rockland 43 6.6 591 93.4 2.3 Sullivan, Ulster 44 7.2 599 92.8 2.4 Westchester 34 4.8 586 95.2 1.8 Hudson Valley Region 211 6.7 2,951 93.3 Lifetime Asthma Diagnosed by a Medical Professional Demographic Yes No C.I.³ Groups n¹ %² n % New York State 2,980 11.5 21,191 88.5 0.7 Orange 86 13.5 552 86.5 3.2 Yes No C.I.³ Locality n¹ %² n % Dutchess, Putnam 78 13.2 549 86.8 3 Orange 86 13.5 552 86.5 3.2 Rockland 61 8.3 572 91.7 2.2 Sullivan, Ulster 85 14.0 557 86.0 3.3 Westchester 65 10.5 554 89.5 2.8 Hudson Valley Region 375 11.9 2,784 88.1 ¹ Percents based on row denominators of less than 50 are unstable and should be used with caution ²Weighted Percent ³95% Confidence Interval # These Counties had significantly different variables from Orange County Exhibit 1C.1 237

EXPANDED BRFSS RESULTS FOR CORE MODULES, ORANGE COUNTY, HUDSON VALLEY REGION AND REST OF NYS, 2003 3 Current Asthma Diagnosed by a Medical Professional Demographic Yes No C.I.³ Groups n¹ %² n % New York State 2,149 7.9 21,956 92.1 0.6 Orange 60 9.0 577 91.0 2.6 Yes No C.I.³ Locality n¹ %² n % Dutchess, Putnam 57 9.3 570 90.7 2.5 Orange 60 9.0 577 91.0 2.6 Rockland 43 6.1 588 93.9 2 Sullivan, Ulster 55 8.6 585 91.4 2.7 Westchester 46 7.5 572 92.5 2.4 Hudson Valley Region 261 8.3 2,892 91.7 Arthritis Diagnosed by a Medical Professional Demographic Yes No C.I.³ Groups n¹ %² n % New York State 7,779 25.7 16,351 74.3 1 Orange 173 23.2 464 76.8 3.5 Yes No C.I.³ Locality n¹ %² n % Dutchess, Putnam 161 23.3 465 76.7 3.7 Orange 173 23.2 464 76.8 3.5 Rockland 188 26.0 447 74.0 3.7 Sullivan, Ulster 219 30.8 423 69.2 4.2 Westchester 159 22.7 460 77.3 3.6 Hudson Valley Region 900 28.5 2,259 71.5 ¹ Percents based on row denominators of less than 50 are unstable and should be used with caution ²Weighted Percent ³95% Confidence Interval # These Counties had significantly different variables from Orange County Exhibit 1C.1 238

EXPANDED BRFSS RESULTS FOR CORE MODULES, ORANGE COUNTY, HUDSON VALLEY REGION AND REST OF NYS, 2003 4 Doctor-Diagnosed Arthritis or Possible Arthritis (Chronic Joint Symptoms Only) Demographic Group n¹ Doctor Diagnosed (%) C.I.³ n Possible CJS Only (%) C.I. n No Arthritis or CJS (%) C.I. New York State 7,779 25.9 1 3,582 14.9 0.8 12675 59.3 1.1 Orange 173 23.4 3.6 101 15.4 3.1 358 61.2 4.3 Demographic Group n¹ Doctor Diagnosed (%) C.I.³ n Possible CJS Only (%) C.I. n No Arthritis or CJS (%) C.I. Dutchess, Putnam 161 23.4 3.7 106 15.7 3.2 356 60.9 4.4 Orange 173 23.4 3.6 101 15.4 3.1 358 61.2 4.3 Rockland 188 26.1 3.7 80 13 3 363 60.9 4.3 Sullivan, Ulster 219 30.9 4.2 107 17 3.6 314 52.1 4.6 Westchester 159 23 3.7 109 18.7 3.7 345 58.3 4.5 Ever Smoked 100 Cigarettes in Your Lifetime Demographic Yes No C.I.³ Groups n¹ %² n % New York State 12,448 45.9 11,685 54.1 1.1 Orange 331 51.1 302 48.9 4.6 Yes No C.I.³ Locality n¹ %² n % Dutchess, Putnam 350 53.6 278 46.4 4.6 Orange 331 51.1 302 48.9 4.6 Rockland 276 42.3 356 57.7 4.4 Sullivan, Ulster 387 58.9 252 41.1 4.6 Westchester 286 45.1 329 54.9 4.6 Hudson Valley Region 1,630 51.8 1,517 48.2 ¹ Percents based on row denominators of less than 50 are unstable and should be used with caution ²Weighted Percent ³95% Confidence Interval # These Counties had significantly different variables from Orange County Exhibit 1C.1 239

EXPANDED BRFSS RESULTS FOR CORE MODULES, ORANGE COUNTY, HUDSON VALLEY REGION AND REST OF NYS, 2003 5 Current Smoker Demographic Yes No C.I.³ Groups n¹ %² n % New York State 5,587 20.3 18,532 79.7 0.9 Orange 148 24.3 484 75.7 4 Yes No C.I.³ Locality n¹ %² n % Dutchess, Putnam 145 23.4 482 76.6 4.1 Orange 148 24.3 484 75.7 4 Rockland # 100 16.0 532 84.0 3.3 Sullivan, Ulster 149 25.4 490 74.6 4.2 Westchester 108 19.0 507 81.0 3.9 Hudson Valley Region 650 20.7 2,495 79.3 Status of Cigarette Smoking Demographic Groups n¹ Everyday Smoker %² C.I.³ n Someday Smoker % C.I. n Former or Never Smoked (%) C.I. New York State 4,258 14.2 0.7 1,329 6.1 0.6 18,532 79.7 0.9 Orange 109 18.2 3.6 39 6.1 2.3 484 75.7 4 Demographic Groups n¹ Everyday Smoker %² C.I.³ n Someday Smoker % C.I. Former or n Never Smoked (%) C.I. Dutchess, Putnam 109 17.9 3.7 36 5.5 2.1 482 76.6 4.1 Orange 109 18.2 3.6 39 6.1 2.3 484 75.7 4 Rockland # 67 10.6 2.7 33 5.5 2.1 532 84 3.3 Sullivan, Ulster 111 19.3 3.8 38 6 2.3 490 74.6 4.2 Westchester # 68 11.3 3 40 7.7 2.9 507 81 3.9 ¹ Percents based on row denominators of less than 50 are unstable and should be used with caution ²Weighted Percent ³95% Confidence Interval # These Counties had significantly different variables from Orange County Exhibit 1C.1 240

EXPANDED BRFSS RESULTS FOR CORE MODULES, ORANGE COUNTY, HUDSON VALLEY REGION AND REST OF NYS, 2003 6 Attempted to Quit - Current Smokers Demographic Yes No C.I.³ Groups n¹ %² n % New York State 3018 58.0 2554 42.0 2.3 Orange 91 63.3 57 36.7 9 Yes No C.I.³ Locality n¹ %² n % Dutchess, Putnam 79 51.6 66 48.4 10.1 Orange 91 63.3 57 36.7 9 Rockland 56 53.8 43 46.2 11.4 Sullivan, Ulster 92 63.7 56 36.3 9.3 Westchester 69 64.4 39 35.6 11.4 Hudson Valley Region 387 59.7 261 40.3 Attempted to Quit - Everyday Smokers Demographic Yes No C.I.³ Groups n¹ %² n % New York State 2056 51.2 2,198 48.8 2.7 Orange 63 58.7 46 41.3 10.7 Yes No C.I.³ Locality n¹ %² n % Dutchess, Putnam 51 43.9 58 56.1 11.5 Orange 63 58.7 46 41.3 10.7 Rockland 38 55.6 29 44.4 13.6 Sullivan, Ulster 62 59.8 49 40.2 10.8 Westchester 35 56.3 33 43.7 13.8 Hudson Valley Region 249 53.7 215 46.3 ¹ Percents based on row denominators of less than 50 are unstable and should be used with caution ²Weighted Percent ³95% Confidence Interval # These Counties had significantly different variables from Orange County Exhibit 1C.1 241

EXPANDED BRFSS RESULTS FOR CORE MODULES, ORANGE COUNTY, HUDSON VALLEY REGION AND REST OF NYS, 2003 7 At Risk for Binge Drinking (Drank in Past Month and had 5 or more Drinks per Drink Occasion) Demographic Yes No C.I.³ Groups n¹ %² n % New York State 3,045 14.1 20,803 85.9 0.8 Orange 68 12.8 561 87.2 3.3 Yes No C.I.³ Locality n¹ %² n % Dutchess, Putnam 74 15.2 548 84.8 3.7 Orange 68 12.8 561 87.2 3.3 Rockland 66 11.9 557 88.1 3 Sullivan, Ulster 72 14.6 564 85.4 3.6 Westchester 61 12.1 550 87.9 3.4 Hudson Valley Region 341 10.9 2,780 89.1 At Risk for Heavy Drinking (Males More Than 2 Drinks and Females More Than 1 Drink per Day in Past Demographic Yes No C.I.³ Groups n¹ %² n % New York State 1,220 4.8 22,697 95.2 0.5 Orange 28 3.9 602 96.1 1.6 Yes No C.I.³ Locality n¹ %² n % Dutchess, Putnam 30 4.4 591 95.6 1.8 Orange 28 3.9 602 96.1 1.6 Rockland 29 4.7 601 95.3 1.9 Sullivan, Ulster 22 4.1 610 95.9 2.1 Westchester 15 2.5 596 97.5 1.4 Hudson Valley Region 124 4.0 3,000 96.0 ¹ Percents based on row denominators of less than 50 are unstable and should be used with caution ²Weighted Percent ³95% Confidence Interval # These Counties had significantly different variables from Orange County Exhibit 1C.1 242

EXPANDED BRFSS RESULTS FOR CORE MODULES, ORANGE COUNTY, HUDSON VALLEY REGION AND REST OF NYS, 2003 8 Ever Had Mammography Screening, Women Aged 40 Years and Older Demographic Yes No C.I.³ Groups n¹ %² n % Female 8,863 90.9 886 9.1 1.1 Orange 222 86.2 32 13.8 4.8 Yes No C.I.³ Locality n¹ %² n % Dutchess, Putnam 225 90.4 19 9.6 4.8 Orange 222 86.2 32 13.8 4.8 Rockland 230 91.8 20 8.2 4 Sullivan, Ulster 244 87.8 33 12.2 4.4 Westchester 233 91.7 23 8.3 3.9 Hudson Valley Region 1,154 90.1 127 9.9 Received Mammography Screening in Past Two Years, Women Aged 40 Years and Older Demographic Yes No C.I.³ Groups n¹ %² n % Female 7,547 77.6 2,133 22.4 1.6 Orange 189 73.8 64 26.2 6 Yes No C.I.³ Locality n¹ %² n % Dutchess, Putnam 174 71.2 67 28.8 6.5 Orange 189 73.8 64 26.2 6 Rockland 203 81.2 46 18.8 5.7 Sullivan, Ulster 199 71.0 75 29.0 6 Westchester 204 79.3 50 20.7 6 Hudson Valley Region 969 76.2 302 23.8 ¹ Percents based on row denominators of less than 50 are unstable and should be used with caution ²Weighted Percent ³95% Confidence Interval # These Counties had significantly different variables from Orange County Exhibit 1C.1 243

EXPANDED BRFSS RESULTS FOR CORE MODULES, ORANGE COUNTY, HUDSON VALLEY REGION AND REST OF NYS, 2003 9 Why Received Mammography Screening, Women Aged 40 Years and Older Demographic Groups n¹ Routine Checkup %² C.I.³ n Breast Problem % C.I. n Had Breast Ca. % C.I. Female 8,050 92.8 0.9 392 4 0.7 363 3.3 0.6 Orange 203 91.2 4.1 10 4.9 3.3 9 3.9 2.7 Demographic Groups n¹ Routine Checkup %² C.I.³ n Breast Problem % C.I. n Had Breast Ca. % C.I. Dutchess, Putnam 209 92.1 4.1 9 4.7 3.4 7 3.2 2.6 Orange 203 91.2 4.1 10 4.9 3.3 9 3.9 2.7 Rockland 207 91.8 3.7 10 3.6 2.4 11 4.6 2.9 Sullivan, Ulster 219 89.8 4.4 14 6.5 3.7 9 3.7 2.6 Westchester 214 91.4 4.5 9 4.7 3.7 9 3.9 2.8 Ever Counseled by Medical Professional on Prevention of STD's Through Condom Use, Aged 64 or Demographic Yes No C.I.³ Groups n¹ %² n % New York State # 2,764 20.0 15,425 80.0 1.1 Orange 61 13.4 442 86.6 4.1 Yes No C.I.³ Locality n¹ %² n % Dutchess, Putnam 61 13.1 434 86.9 3.7 Orange 61 13.4 442 86.6 4.1 Rockland 50 12.4 423 87.6 3.8 Sullivan, Ulster 79 18.3 415 81.7 4.7 Westchester 78 19.5 371 80.5 4.8 Hudson Valley Region 329 13.6 2,085 86.4 ¹ Percents based on row denominators of less than 50 are unstable and should be used with caution ²Weighted Percent ³95% Confidence Interval # These Counties had significantly different variables from Orange County Exhibit 1C.1 244

EXPANDED BRFSS RESULTS FOR CORE MODULES, ORANGE COUNTY, HUDSON VALLEY REGION AND REST OF NYS, 2003 10 Sexually Active, Age 18-64 Years Old Demographic Yes No C.I.³ Groups n¹ %² n % New York State # 13,647 82.0 3,449 18.0 1 Orange 405 88.5 65 11.5 3.3 Yes No C.I.³ Locality n¹ %² n % Dutchess, Putnam 388 83.1 77 16.9 4.4 Orange 405 88.5 65 11.5 3.3 Rockland 355 84.5 85 15.5 3.6 Sullivan, Ulster 376 84.5 90 15.5 4.3 Westchester 344 82.6 75 17.4 4.8 Hudson Valley Region 1,868 82.7 392 17.3 Multiple Partners in Past 12 Months, Sexually Active, Aged 64 or Younger Demographic Yes No C.I.³ Groups n¹ %² n % New York State 1084 10.1 12563 89.9 1 Orange 21 6.1 384 93.9 3.9 Yes No C.I.³ Locality n¹ %² n % Dutchess, Putnam 28 9.7 360 90.3 4.1 Orange 21 6.1 384 93.9 3.9 Rockland 30 8.3 325 91.7 3.5 Sullivan, Ulster 35 12.2 341 87.8 4.6 Westchester 30 8.0 314 92.0 3.5 Hudson Valley Region 144 7.7 1724 92.3 ¹ Percents based on row denominators of less than 50 are unstable and should be used with caution ²Weighted Percent ³95% Confidence Interval # These Counties had significantly different variables from Orange County Exhibit 1C.1 245

EXPANDED BRFSS RESULTS FOR CORE MODULES, ORANGE COUNTY, HUDSON VALLEY REGION AND REST OF NYS, 2003 11 Used Condom Last Time Had Sexual Intercourse, Aged 64 or Younger Demographic Yes No C.I.³ Groups n¹ %² n % New York State # 2,948 28.9 11,019 71.1 1.4 Orange 85 21.0 321 79.0 5 Yes No C.I.³ Locality n¹ %² n % Dutchess, Putnam 77 22.5 312 77.5 5.2 Orange 85 21.0 321 79.0 5 Rockland 87 22.9 281 77.1 5 Sullivan, Ulster 86 24.4 301 75.6 5.4 Westchester 99 28.0 251 72.0 5.7 Hudson Valley Region 434 22.8 1466 77.2 Birth Control (BC) Use To Prevent Pregnancy Among Reproductive Aged Men (18-59) and Women (18-44) Demographic Groups n¹ Use BC (%²) C.I.³ n No BC at risk (%) C.I. n No BC (%) C.I. New York State # 7,887 61.4 1.5 1,661 15.1 1.1 2,961 23.4 1.3 Orange 236 69.5 5.6 52 15.6 4.5 55 14.8 4.2 Use BC No BC at risk No BC Locality n¹ %² C.I.³ n % C.I. n % C.I. Dutchess, Putnam 211 62.6 6.1 53 15.8 4.4 76 21.6 5.4 Orange 236 69.5 5.6 52 15.6 4.5 55 14.8 4.2 Rockland # 176 56.3 6.2 68 22.5 5.3 72 21.2 5.1 Sullivan, Ulster 196 62.6 6.5 52 17.5 4.9 73 19.9 5.6 Westchester 177 58.9 6.6 47 14.6 4.3 74 26.5 6.3 ¹ Percents based on row denominators of less than 50 are unstable and should be used with caution ²Weighted Percent ³95% Confidence Interval # These Counties had significantly different variables from Orange County Exhibit 1C.1 246

EXPANDED BRFSS RESULTS FOR CORE MODULES, ORANGE COUNTY, HUDSON VALLEY REGION AND REST OF NYS, 2003 12 Physician-Diagnosed Heart Attack, Angina or Stroke Demographic Yes No C.I.³ Groups n¹ %² n % New York State 2,086 6.9 21,695 93.1 0.5 Orange 57 7.1 577 92.9 2 Yes No C.I.³ Locality n¹ %² n % Dutchess, Putnam 40 5.7 573 94.3 2 Orange 57 7.1 577 92.9 2 Rockland 41 5.5 576 94.5 1.8 Sullivan, Ulster 57 8.0 579 92.0 2.2 Westchester 47 7.1 559 92.9 2.3 Hudson Valley Region 242 7.8 2864 92.2 Physician-Diagnosed Coronary Heart Disease (Heart Attack or Angina) Demographic Yes No C.I.³ Groups n¹ %² n % New York State 1,738 5.8 22,029 94.2 0.5 Orange 48 6.2 586 93.8 1.9 Yes No C.I.³ Locality n¹ %² n % Dutchess, Putnam 33 4.6 580 95.4 1.7 Orange 48 6.2 586 93.8 1.9 Rockland 30 4.3 587 95.7 1.6 Sullivan, Ulster 53 7.4 583 92.6 2.1 Westchester 39 6.4 567 93.6 2.2 Hudson Valley Region 242 6.5 3,497 93.5 ¹ Percents based on row denominators of less than 50 are unstable and should be used with caution ²Weighted Percent ³95% Confidence Interval # These Counties had significantly different variables from Orange County Exhibit 1C.1 247

EXPANDED BRFSS RESULTS FOR CORE MODULES, ORANGE COUNTY, HUDSON VALLEY REGION AND REST OF NYS, 2003 13 Ever Had Prostate Specific Antigen Test, Men Aged 40 and Older Demographic Yes No C.I.³ Groups n¹ %² n % Male 3,727 62.9 2,191 37.1 2.3 Orange 100 61.5 60 38.5 8.2 Yes No C.I.³ Locality n¹ %² n % Dutchess, Putnam 104 63.1 53 36.9 8.6 Orange 100 61.5 60 38.5 8.2 Rockland 106 68.7 53 31.3 7.9 Sullivan, Ulster 115 67.9 57 32.1 7.7 Westchester 93 67.0 48 33.0 8.6 Hudson Valley Region 518 65.7 271 34.3 Ever Had a Digital Rectal Exam, Men Aged 40 and Older Demographic Yes No C.I.³ Groups n¹ %² n % Male 4,971 78.5 1,183 21.5 2 Orange 130 78.6 34 21.4 6.8 Yes No C.I.³ Locality n¹ %² n % Dutchess, Putnam 137 85.3 24 14.7 6.1 Orange 130 78.6 34 21.4 6.8 Rockland 127 79.0 33 21.0 6.9 Sullivan, Ulster 146 83.7 31 16.3 6 Westchester 126 83.4 24 16.6 6.6 Hudson Valley Region 666 82.0 146 18.0 ¹ Percents based on row denominators of less than 50 are unstable and should be used with caution ²Weighted Percent ³95% Confidence Interval # These Counties had significantly different variables from Orange County Exhibit 1C.1 248

EXPANDED BRFSS RESULTS FOR CORE MODULES, ORANGE COUNTY, HUDSON VALLEY REGION AND REST OF NYS, 2003 14 Received Prostate Specific Antigen Test in the Past Two Years, Men Aged 40 and Older Demographic Yes No C.I.³ Groups n¹ %² n % Male 3,225 56.0 2,652 44.0 2.3 Orange 83 53.4 74 46.6 8.5 Yes No C.I.³ Locality n¹ %² n % Dutchess, Putnam 95 58.2 62 41.8 8.7 Orange 83 53.4 74 46.6 8.5 Rockland 89 59.0 69 41.0 8.4 Sullivan, Ulster 96 58.2 76 41.8 8.1 Westchester 83 62.3 56 37.7 8.9 Hudson Valley Region 446 57.0 337 43.0 Ever Been Told by a Medical Professional that Had Prostate Cancer, Men Aged 40 and Older Demographic Yes No C.I.³ Groups n¹ %² n % Male 259 3.2 5,941 96.8 0.7 Orange 6 2.9 158 97.1 2.5 Yes No C.I.³ Locality n¹ %² n % Dutchess, Putnam 7 4.8 154 95.2 3.5 Orange 6 2.9 158 97.1 2.5 Rockland 8 5.5 152 94.5 3.9 Sullivan, Ulster 7 3.6 171 96.4 2.8 Westchester 4 2.5 148 97.5 2.7 Hudson Valley Region 32 3.9 783 96.1 ¹ Percents based on row denominators of less than 50 are unstable and should be used with caution ²Weighted Percent ³95% Confidence Interval # These Counties had significantly different variables from Orange County Exhibit 1C.1 249

EXPANDED BRFSS RESULTS FOR CORE MODULES, ORANGE COUNTY, HUDSON VALLEY REGION AND REST OF NYS, 2003 15 Ever Used a Blood Stool Test at Home, Aged 50 and Older Demographic Yes No C.I.³ Groups n¹ %² n % New York State 4,835 40.6 5,970 59.4 1.7 Orange 111 42.6 146 57.4 6.6 Yes No C.I.³ Locality n¹ %² n % Dutchess, Putnam 117 43.5 152 56.5 6.7 Orange 111 42.6 146 57.4 6.6 Rockland 114 146 56.7 6.7 Sullivan, Ulster 115 39.4 185 60.6 6.3 Westchester 114 43.3 156 56.7 6.9 Hudson Valley Region 571 42.1 785 57.9 Used a Blood Stool Test at Home in the Past Year, Aged 50 and Older Demographic Yes No C.I.³ Groups n¹ %² n % New York State 2,085 18.7 8,589 81.3 1.3 Orange 48 17.5 206 82.5 5.1 Yes No C.I.³ Locality n¹ %² n % Dutchess, Putnam 45 16.9 222 83.1 5.1 Orange 48 17.5 206 82.5 5.1 Rockland 39 15.2 218 84.8 5 Sullivan, Ulster 42 15.5 253 84.5 4.8 Westchester 62 24.5 208 75.5 6 Hudson Valley Region 236 17.6 1,107 82.4 ¹ Percents based on row denominators of less than 50 are unstable and should be used with caution ²Weighted Percent ³95% Confidence Interval # These Counties had significantly different variables from Orange County Exhibit 1C.1 250

EXPANDED BRFSS RESULTS FOR CORE MODULES, ORANGE COUNTY, HUDSON VALLEY REGION AND REST OF NYS, 2003 16 Used a Blood Stool Test at Home in the Past 2 Years, Aged 50 and Older Demographic Yes No C.I.³ Groups n¹ %² n % New York State 3,029 26.9 7,645 73.1 1.5 Orange 69 26.7 185 73.3 6 Yes No C.I.³ Locality n¹ %² n % Dutchess, Putnam 66 26.5 201 73.5 6.1 Orange 69 26.7 185 73.3 6 Rockland 64 25.2 193 74.8 5.9 Sullivan, Ulster 61 23.5 234 76.5 5.7 Westchester 79 29.5 191 70.5 6.2 Hudson Valley Region 339 25.2 1,004 74.8 Ever Had a Sigmoidoscopy or Colonoscopy, Aged 50 and Older Demographic Yes No C.I.³ Groups n¹ %² n % New York State 5,592 52.4 5,219 47.6 1.8 Orange 141 52.3 117 47.7 6.7 Yes No C.I.³ Locality n¹ %² n % Dutchess, Putnam 148 56.2 121 43.8 6.8 Orange 141 52.3 117 47.7 6.7 Rockland 159 58.6 102 41.4 6.8 Sullivan, Ulster 148 53.0 151 47.0 6.4 Westchester 163 61.9 106 38.1 6.8 Hudson Valley Region 759 56.0 597 44.0 ¹ Percents based on row denominators of less than 50 are unstable and should be used with caution ²Weighted Percent ³95% Confidence Interval # These Counties had significantly different variables from Orange County Exhibit 1C.1 251

EXPANDED BRFSS RESULTS FOR CORE MODULES, ORANGE COUNTY, HUDSON VALLEY REGION AND REST OF NYS, 2003 17 Had a Sigmoidoscopy or Colonoscopy in the Past 10 Years, Aged 50 and Older Demographic Yes No C.I.³ Groups n¹ %² n % New York State 5,179 49.6 5,562 50.4 1.8 Orange 133 50.2 123 49.8 6.7 Yes No C.I.³ Locality n¹ %² n % Dutchess, Putnam 134 51.3 131 48.7 6.9 Orange 133 50.2 123 49.8 6.7 Rockland 146 55.2 113 44.8 6.8 Sullivan, Ulster 134 48.8 164 51.2 6.5 Westchester 154 59.7 112 40.3 6.9 Hudson Valley Region 701 52.2 643 47.8 Had a Blood Stool Test Using a Home Kit in the Past Year or Had a Lower Endoscopy in the Past 10 Demographic Yes No C.I.³ Groups n¹ %² n % New York State 5,993 55.5 4,882 44.5 1.8 Orange 143 54.6 114 45.4 6.7 Yes No C.I.³ Locality n¹ %² n % Dutchess, Putnam 150 54.9 120 45.1 6.8 Orange 143 54.6 114 45.4 6.7 Rockland 158 59.6 104 40.4 6.7 Sullivan, Ulster 150 53.2 151 46.8 6.4 Westchester 170 63.2 100 36.8 6.8 Hudson Valley Region 771 56.7 589 43.3 ¹ Percents based on row denominators of less than 50 are unstable and should be used with caution ²Weighted Percent ³95% Confidence Interval # These Counties had significantly different variables from Orange County Exhibit 1C.1 252

EXPANDED BRFSS RESULTS FOR CORE MODULES, ORANGE COUNTY, HUDSON VALLEY REGION AND REST OF NYS, 2003 18 Doctor-Diagnosed Arthritis or Possible Arthritis (Chronic Joint Symptoms Only) Demographic Group n¹ Doctor Diagnosed (%) C.I.³ n Possible CJS Only (%) C.I. n No Arthritis or CJS (%) C.I. New York State 7,779 25.9 1 3,582 14.9 0.8 12,675 59.3 1.1 Orange 173 23.4 3.6 101 15.4 3.1 358 61.2 4.3 Demographic Group n¹ Doctor Diagnosed (%) C.I.³ n Possible CJS Only (%) C.I. n No Arthritis or CJS (%) C.I. Dutchess, Putnam 161 23.4 3.7 106 15.7 3.2 356 60.9 4.4 Orange 173 23.4 3.6 101 15.4 3.1 358 61.2 4.3 Rockland 188 26.1 3.7 80 13 3 363 60.9 4.3 Sullivan, Ulster 219 30.9 4.2 107 17 3.6 314 52.1 4.6 Westchester 159 23 3.7 109 18.7 3.7 345 58.3 4.5 Status of Cigarette Smoking Demographic Groups n¹ Everyday Smoker %² C.I.³ n Someday Smoker % C.I. n Former or Never Smoked (%) C.I. New York State 4,258 14.2 0.7 1,329 6.1 0.6 18,532 79.7 0.9 Orange 109 18.2 3.6 39 6.1 2.3 484 75.7 4 Demographic Groups n¹ Everyday Smoker %² C.I.³ n Someday Smoker % C.I. n Former or Never Smoked (%) C.I. Dutchess, Putnam 109 17.9 3.7 36 5.5 2.1 482 76.6 4.1 Orange 109 18.2 3.6 39 6.1 2.3 484 75.7 4 Rockland # 67 10.6 2.7 33 5.5 2.1 532 84 3.3 Sullivan, Ulster 111 19.3 3.8 38 6 2.3 490 74.6 4.2 Westchester # 68 11.3 3 40 7.7 2.9 507 81 3.9 ¹ Percents based on row denominators of less than 50 are unstable and should be used with caution ²Weighted Percent ³95% Confidence Interval # These Counties had significantly different variables from Orange County Exhibit 1C.1 253

EXPANDED BRFSS RESULTS FOR CORE MODULES, ORANGE COUNTY, HUDSON VALLEY REGION AND REST OF NYS, 2003 19 Why Received Mammography Screening, Women Aged 40 Years and Older Demographic Groups n¹ Routine Checkup %² C.I.³ n Breast Problem % C.I. n Had Breast Ca. % C.I. Female 8,050 92.8 0.9 392 4 0.7 363 3.3 0.6 Orange 203 91.2 4.1 10 4.9 3.3 9 3.9 2.7 Demographic Groups n¹ Routine Checkup %² C.I.³ n Breast Problem % C.I. n Had Breast Ca. % C.I. Dutchess, Putnam 209 92.1 4.1 9 4.7 3.4 7 3.2 2.6 Orange 203 91.2 4.1 10 4.9 3.3 9 3.9 2.7 Rockland 207 91.8 3.7 10 3.6 2.4 11 4.6 2.9 Sullivan, Ulster 219 89.8 4.4 14 6.5 3.7 9 3.7 2.6 Westchester 214 91.4 4.5 9 4.7 3.7 9 3.9 2.8 Birth Control (BC) Use To Prevent Pregnancy Among Reproductive Aged Men (18-59) and Women (18-44) Demographic Groups n¹ Use BC (%²) C.I.³ n No BC at risk (%) C.I. n No BC (%) C.I. New York State # 7887 61.4 1.5 1661 15.1 1.1 2961 23.4 1.3 Orange 236 69.5 5.6 52 15.6 4.5 55 14.8 4.2 Use BC No BC at risk No BC Locality n¹ %² C.I.³ n % C.I. n % C.I. Dutchess, Putnam 211 62.6 6.1 53 15.8 4.4 76 21.6 5.4 Orange 236 69.5 5.6 52 15.6 4.5 55 14.8 4.2 Rockland # 176 56.3 6.2 68 22.5 5.3 72 21.2 5.1 Sullivan, Ulster 196 62.6 6.5 52 17.5 4.9 73 19.9 5.6 Westchester 177 58.9 6.6 47 14.6 4.3 74 26.5 6.3 ¹ Percents based on row denominators of less than 50 are unstable and should be used with caution ²Weighted Percent ³95% Confidence Interval # These Counties had significantly different variables from Orange County Source: New York State Department of Health BRFSS Health Survey http://www.health.state.ny.us/nysdoh/brfss/index.htm Exhibit 1C.1 254

EXPANDED BRFSS RESULTS FOR OPTIONAL MODULES, ORANGE COUNTY, HUDSON VALLEY REGION AND REST OF NYS, 2003 Ever had Blood Cholesterol Checked Yes No Locality n¹ %² n % C.I.³ Dutchess, Putnam 518 84.6 78 15.4 3.8 Orange 537 82.5 84 17.5 4 Rockland 529 85.4 68 14.6 3.7 Westchester 505 82.3 80 17.7 4.2 Had Blood Cholesterol Checked in the Past Five Years Yes No Locality n¹ %² n % C.I.³ Dutchess, Putnam 475 79.5 107 20.5 4.1 Orange 514 80 100 20 4.1 Rockland 498 80.9 91 19.1 4 Westchester 479 78.7 102 21.3 4.4 Adults with a Disability Yes No Locality n¹ %² n % C.I.³ Orange 131 17.9 494 82.1 3.2 Rockland 110 16.1 495 83.9 3.2 Westchester 103 14 497 86 2.9 Eat Five Fruits or Vegetable Servings per Day Yes No Locality n¹ %² n % C.I.³ Dutchess, Putnam 184 28.6 420 71.4 4 Orange 180 25.2 450 74.8 3.9 Rockland 170 26.9 441 73.1 4 Westchester 194 31.6 400 68.4 4.3 ¹ Percents based on row denominators of less than 50 are unstable and should be used with caution ²Weighted Percent ³95% Confidence Interval 4 These Counties had significantly different variables from Orange County Exhibit 1C.2 255

EXPANDED BRFSS RESULTS FOR OPTIONAL MODULES, ORANGE COUNTY, HUDSON VALLEY REGION AND REST OF NYS, 2003 Ever Been Told Have High Blood Pressure by a Medical Professional Yes No Locality n¹ %² n % C.I.³ Dutchess, Putnam 154 23.6 448 76.4 3.7 Orange 170 23.2 458 76.8 3.6 Rockland 147 22.1 458 77.9 3.6 Had a Fall in Past Three Months No fall Fall with injury Fall no injury Locality n¹ %² C.I.³ n % C.I. n % C.I. Dutchess, Putnam 279 85.9 4.3 15 5.7 3.1 34 8.3 3.2 Orange 269 81.5 4.6 27 6.9 2.8 40 11.6 3.9 Rockland 279 83.1 4.4 24 6.8 3 39 10.1 3.5 Westchester 280 87.2 4.1 16 4.3 2.4 30 8.6 3.5 Had a Flu Shot in the Past 12 Months, Aged 65 and Older Yes No Locality n¹ %² n % C.I.³ Dutchess, Putnam 65 59 46 41 10.2 Orange 79 66.9 38 33.1 9.1 Rockland 89 69.4 34 30.6 9.2 Sullivan, Ulster 93 71.7 39 28.3 8.3 Westchester 97 67.8 39 32.2 9 Had a Flushot in the Past 12 Months Yes No Locality n¹ %² n % C.I.³ Dutchess, Putnam 164 25.2 434 74.8 3.9 Orange 207 31.6 418 68.4 4.4 Rockland 192 28.1 409 71.9 3.9 Sullivan, Ulster 205 32.2 419 67.8 4.5 Westchester 215 32 375 68 4.3 ¹ Percents based on row denominators of less than 50 are unstable and should be used with caution ²Weighted Percent ³95% Confidence Interval 4 These Counties had significantly different variables from Orange County Exhibit 1C.2 256

EXPANDED BRFSS RESULTS FOR OPTIONAL MODULES, ORANGE COUNTY, HUDSON VALLEY REGION AND REST OF NYS, 2003 Ever Had a Pneumonia Shot, Aged 65 and Older Yes No Locality n¹ %² n % C.I.³ Dutchess, Putnam 74 75 33 25 8.4 Orange 70 60.4 44 39.6 9.7 Rockland 76 60 44 40 9.8 Sullivan, Ulster 78 60 49 40 9.6 Westchester 71 53 54 47 9.8 Ever Had a Pneumonia Shot Yes No Locality n¹ %² n % C.I.³ Dutchess, Putnam 132 23.8 430 76.2 4.1 Orange 118 20 469 80 3.9 Rockland 116 18.3 436 81.7 3.4 Sullivan, Ulster 149 25.3 435 74.7 4.2 Westchester 133 22.2 415 77.8 4.1 Have Had Permanent Teeth Removed because of Tooth Decay or Gum Yes No Locality n¹ %² n % C.I.³ Orange 342 51 272 49 4.7 Rockland 308 48.9 282 51.1 4.6 Having Seen a Dental Professional in the Past 12 Months Yes No Locality n¹ %² n % C.I.³ Orange 427 73.7 161 26.3 4.1 Rockland 4 474 82.2 103 17.8 3.4 ¹ Percents based on row denominators of less than 50 are unstable and should be used with caution ²Weighted Percent ³95% Confidence Interval 4 These Counties had significantly different variables from Orange County Exhibit 1C.2 257

EXPANDED BRFSS RESULTS FOR OPTIONAL MODULES, ORANGE COUNTY, HUDSON VALLEY REGION AND REST OF NYS, 2003 Trying to Lose Weight Yes No Locality n¹ %² n % C.I.³ Orange 329 50 294 50 4.7 Rockland 316 50.4 288 49.6 4.6 Westchester 276 45.4 314 54.6 4.7 Trying to Maintain Current Weight of Those not Trying to Lose Weight Yes No Locality n¹ %² n % C.I.³ Orange 171 54.7 122 45.3 6.9 Rockland 170 60.3 113 39.7 6.6 Westchester 214 65.9 98 34.1 6.3 Eating Fewer Calories or Less Fat to Lose or Maintain Weight Yes No Locality n¹ %² n % C.I.³ Orange 396 79 97 21 4.4 Rockland 383 76.5 97 23.5 4.7 Westchester 366 76.1 113 23.9 4.6 Using Physical Exercise to Lose or Maintain Weight Yes No Locality n¹ %² n % C.I.³ Orange 358 74 141 26 4.4 Rockland 325 68.8 159 31.2 4.6 Westchester 348 72.6 140 27.4 4.6 ¹ Percents based on row denominators of less than 50 are unstable and should be used with caution ²Weighted Percent ³95% Confidence Interval 4 These Counties had significantly different variables from Orange County Exhibit 1C.2 258

EXPANDED BRFSS RESULTS FOR OPTIONAL MODULES, ORANGE COUNTY, HUDSON VALLEY REGION AND REST OF NYS, 2003 Ever Had a Pap Smear Yes No Locality n¹ %² n % C.I.³ Orange 321 96.4 10 3.6 2.3 Rockland 295 92.5 19 7.5 3.6 Sullivan, Ulster 292 91.9 15 8.1 4.6 Westchester 298 95.5 11 4.5 3.2 Had a Pap Smear in Past 3 Years Yes No Locality n¹ %² n % C.I.³ Orange 280 85.9 47 14.1 4.1 Rockland 273 87.3 40 12.7 4.2 Sullivan, Ulster 248 80.3 57 19.7 5.6 Westchester 269 86.9 38 13.1 4.8 ¹ Percents based on row denominators of less than 50 are unstable and should be used with caution ²Weighted Percent ³95% Confidence Interval 4 These Counties had significantly different variables from Orange County Source: New York State Department of Health BRFSS Expanded Health Survey http://www.health.state.ny.us/nysdoh/brfss/index.htm Exhibit 1C.2 259

ADOLESCENT/YOUNG ADULT SUICIDE (AGES 15-19) DEATHS AND DEATH RATES PER 100,000 RESIDENTS, 2004-2006 Deaths Population Crude Region/County 2004 2005 2006 Total 2005 Rate Orange 2 1 2 5 29,417 5.7 Hudson Valley Region 11 5 6 22 161,827 4.5 New York State 68 56 51 175 1,318,372 4.4 Source: 2004-2006 Vital Statistics Data as of March, 2008 Exhibit 1C.3 260

Exhibit 1C. 4a 261

Exhibit 1C. 4b 262

Exhibit 1.D.1 263

ORANGE COUNTY COMMUNITY HEALTH ASSESSMENT 2010-2013 SECTION TWO: LOCAL HEALTH UNIT CAPACITY PROFILE A. ORGANIZATIONAL STRUCTURE AND PROGRAM DESCRIPTION Overview History The Orange County Department of Health (OCDOH) was formed in 1969 as a full service department in a chartered county with legislative oversight and an advisory Board of Health. The Department operates under the NYS Public Health Code and Titles 10 and 6 of the Official Compilation of Codes, Rules, and Regulations of the State of New York. Prior to 1969, public health services were provided through the New York State Department of Health (NYSDOH) district office in Middletown, which also served Sullivan and Putnam Counties and the city of Beacon in Dutchess County. In the 1960s, NYSDOH encouraged the creation of county health departments in counties with a population base of 100,000 or more to better meet resident needs. NYSDOH and the public health offices in the county s cities initially provided staff for the newly formed Orange County Health Department. Mission The mission of the Department of Health is to monitor and protect the health of residents of Orange County, to prevent disease and disability, provide education regarding healthful living, and assure healthful environmental conditions. Scope of Services The Department provides public health services countywide. Outreach, prevention, education and intervention services are strategically located in communities of high need. Services include: Communicable and chronic disease prevention and control; Tuberculosis and sexually transmitted disease (STD) clinics providing screening, diagnosis and treatment; HIV clinics offering testing, counseling, and referral for treatment; Immunizations pediatric, adolescent, adult and travel; Home health services; Environmental inspections and engineering reviews; Screening and monitoring services for at-risk infants and toddlers; early intervention and preschool special education services; Community health outreach, education, and referral services (including preventive and primary care, adolescent health, family planning, prenatal, dental, lead poisoning, injury prevention); Epidemiological surveillance and research; Nutrition services and WIC; Programs to improve perinatal care, support for medical care of physically handicapped children and adult polio clients and public health emergency preparedness and response; and Office of the Medical Examiner. Administration and Organizational Structure Overall leadership and direction for the Department is provided by the Commissioner and Deputy Commissioner of Health. The current Commissioner of Health is Jean M. Hudson, M.D., M.P.H., a boardcertified family practice physician. Dr. Hudson is a highly experienced public health administrator who was appointed to her position in 2003 and previously served as the Deputy Commissioner for Community Health Services in Westchester County. In addition to public health, she has practiced in the fields of emergency, acute care, and community medicine. The Deputy Commissioner of Health is Christopher J. Dunleavy who has extensive experience in public agency administration and leadership. The Department of Health consists of seven major Divisions/Offices the Divisions of Public Health Nursing, Environmental Health, Intervention Services, Community Health Outreach, Fiscal, and Offices of Public Health Emergency Response and the Medical Examiner. The Public Health Nursing Division, administered by Marilyn Ejercito, R.N., B.S.N., M.S., Director of Patient Services, includes the WIC Program (Special Supplemental Food Program for Women, Infants, and Children), disease prevention and control programs, all clinic operations (e.g., HIV, STD, and TB), the Immunization Action Program, and the Certified Home Health Agency and Long-Term Home Health Care Programs. The Environmental Health Division, headed by Matthias Schleiffer, P.E., Assistant Commissioner, consists of two Bureaus - Sanitary Engineering and Sanitary Control. The Intervention Services Division, lead by Sheila Warren, R.N., M.Ed. Director, includes Early Intervention, Preschool, Special Health Care Needs, Physically Handicapped Children s, and ICHAP/Child Find Programs. The Community Health Outreach Division Director, Robert Deitrich, oversees multiple grant programs targeted to high-risk communities and provides education on public health issues throughout Orange County. The Office of Public Health Response Director, Christopher Ericson, assists the Commissioner of Health in the planning and coordination of the Orange County Community Health Assessment 2010-2013 Section II 1

Department s response to any imminent or emerging threats to the public s health. In 2008, Orange County transitioned from an elected Coroner system to a Medical Examiner system after many years of consideration by the Legislature. The Office of the Medical Examiner was placed under the Department of Health for Article 6 reimbursement. The Division/Office Directors, Commissioner, and Deputy Commissioner meet weekly as an administrative leadership team to review progress towards objectives, emerging service trends and needs, and for strategic planning. Tables of Organization for the Department, each Division, and the Office of the Medical Examiner are provided in Exhibit 2.1 (a-i) located at the end of Section II. Contact information for each program is provided in Exhibit 2.2. A description of programs and services provided to county residents by each Division/Office follows. Public Health Nursing Division The Public Health Nursing Division provides chronic and communicable disease prevention and control services as well as comprehensive skilled services to reduce the severity and progression of disease and prevent disease-related disabilities. Communicable disease prevention and control activities include comprehensive surveillance, follow-up, and clinic services. The Division has four offices located in Orange County s three major cities - Middletown, Port Jervis, Newburgh, and in Goshen, the county seat. Disease Prevention and Control Services With the continuing threat of new and emerging infections, in addition to known reportable diseases and syndromes, the Division of Public Health Nursing s role in ongoing disease investigation and surveillance continues. Nursing staff monitor electronic reporting of laboratory reports, calls from the public, schools, colleges, workplaces and residents in the community. The Nursing Division coordinates Rabies prevention in the county. All possible exposures reported in the county by local emergency rooms, health care providers, and directly by community residents are carefully reviewed. If a valid exposure has occurred according to the NYSDOH guidelines, treatment is facilitated free-of-charge. Syndromic surveillance implemented as a result of public health emergency planning efforts of school absenteeism in sentinel districts and emergency room chief complaints is ongoing. Case follow-up is accomplished through interviews, contact tracing, data analysis, initiating control measures, making recommendations, and reporting findings to the appropriate sources. As a component of disease prevention and control activities, targeted clinical services are provided to county residents to prevent and promote early detection of communicable diseases including childhood/adolescent immunization for all vaccine preventable diseases; adult immunization including influenza and pneumococcal vaccination; travel immunization; sexually transmitted disease (STD) screening and treatment; HIV counseling and testing; and screening and treatment for Tuberculosis. Perinatal Hepatitis B Program The Perinatal Hepatitis B Program provides Public Health Nurse (PHN) follow-up for Hepatitis B Positive mothers and infants to ensure completion of the Hepatitis B series and post-vaccination serology testing of exposed infants as recommended by NYSDOH. Education is provided to the family and all contacts about Hepatitis B infection and testing is made available for contacts as appropriate. Certified Home Health Agency (CHHA) Therapeutic and preventive health services are provided to homebound residents of all ages throughout Orange County. Upon referral by the patient's physician, home health services are provided based on illness, disability, or recent discharge from the hospital. The Home Health Agency is certified to participate in Medicare and Medicaid. Services include: nursing, physical therapy, occupational therapy, speech and audiology, medical social work, nutrition, respiratory, home health and personal care aide services. Due to earlier hospital discharges, patients are returning home in need of more intensive and continuing skilled care, education, and close monitoring. The goals of intensive services in the home are to improve the patient's overall physical condition, patient and family understanding of disease processes and medical regimens, and assist the patient and family in achieving a high level of independence to maintain their health. Persons entering Long Term Care Facilities in New York State are required to have an assessment by a trained and certified health professional using the PRI (Patient Review Instrument) to determine the appropriate level of care. The request can originate from a spouse, family member, facility or physician. Individuals are assessed by OCDOH nursing staff, which is a valuable service to the patients and their families applying for nursing home placement, as this is a complicated and lengthy process. Long Term Home Health Care Program (LTHHCP) The Long Term Home Health Care Program provides a coordinated plan of health care and social services delivered to disabled, infirm, or invalid persons in their own homes. The LTHHCP is an alternative level of care for individuals who would otherwise require placement in a nursing home or health related facility. The ability to maintain patients in the home setting enables them to thrive both physically and mentally and is accomplished at a lesser cost to the patient, family, and insurers. Clinic Services Tuberculosis clinics are offered throughout the county. Patients are diagnosed by an attending pulmonologist and followed by the Health Department. Through Directly Observed Therapy (DOT), patients with active Orange County Community Health Assessment 2010-2013 Section II 2

tuberculosis who are no longer communicable can receive treatment at home under daily supervision. Case investigations are carried out in all situations where an infection occurs; this may be in a school, correctional facility, homeless shelter, or workplace. Sexually Transmitted Disease (STD) Clinics are confidential and are held in Newburgh and Middletown. HIV counseling and testing (both anonymous and confidential) are conducted in Middletown and Newburgh sites weekly by NYSDOH certified HIVcounselors. In October 2007 the TB Control program added two physicians to staff the clinics in both Middletown and Newburgh. An additional clinic was added in Middletown to ensure a physician is available to patients twice a month in each location. Medication pick-up at clinics is by appointment only. The Health Department conducts immunization clinics by appointment throughout the county on a bi-weekly basis. Immunizations are provided to residents from two months of age through college age. The clinic provides age-appropriate vaccination against diphtheria, polio, pertussis, tetanus, measles, mumps, rubella, varicella, meningitis, hepatitis A, hepatitis B, rotavirus, human papillomavirus (HPV), haemophilus influenza (HIB), influenza and pneumonia. Influenza and pneumoccocal immunization for senior citizens and high risk adults are offered each fall in multiple locations throughout the county. Adult and Travel Immunization Clinics are conducted monthly in the Goshen office. Adults can receive hepatitis A, hepatitis B, human papillomavirus (HPV), MMR, polio, meningitis varicella, rabies (pre-exposure only), tetanus, typhoid and yellow fever vaccines. This clinic is by appointment and there is a fee for each immunization administered. TwinRix (hepatitis A and B) vaccine is now offered to patients attending Sexually Transmitted Disease clinics in Newburgh and Middletown. Perinatal Hepatitis B Program The Perinatal Hepatitis B Program provides PHN followup for hepatitis B positive mothers and infants to ensure completion of the hepatitis B series and postvaccination serology testing of exposed infants as recommended by NYSDOH. Education is provided to the family and all contacts about hepatitis B infection and testing is made available for contacts as appropriate. From 2004 to 2008, an average of nine hepatitis B positive mothers and infants were served annually. There is a need for consistent reporting of hepatitis B positive mothers by hospitals and laboratories to OCDOH to facilitate timelier follow-up vs. the delay inherent in receiving these reports through NYSDOH. Physician and newborn nursery education is needed to improve consistency in providing the hepatitis B birth dose as recommended by NYSDOH/CDC. WIC Program The federally-funded WIC program issues vouchers for food and provides nutritional education to eligible participants based on individual nutritional assessments. Services provided to the WIC population help to ensure healthy pregnancies, good birth outcomes, and healthy children in families who are at risk medically, nutritionally, and financially. Nutrition education is provided based on individual dietary assessment conducted by qualified nutrition professionals. Breastfeeding promotion and education for all pregnant women encourage this feeding method. Additionally, the immunization and health care status of participants are monitored. High-risk care plans are developed for those in need. Hematological and anthropometric services and screening and referral for substance abuse and smoking cessation are also provided. See Exhibits 2.3-2.4 at the end of Section II for the Clinic Services Schedule for OCDOH Programs. Intervention Services Division The Division administers the following programs: Early Intervention Services Program The NYSDOH grant-funded Early Intervention (EI) Services Program provides education and training for the families of children from birth up to 3 years of age with a developmental delay or conditions that result in a developmental delay. Physical, occupational and speech therapists, special educators, social workers and nutritionists provide family-centered education and training in the child s natural environment whenever possible. The goal is to enhance each child s potential for growth and development by developing family members skills in providing a stimulating and nurturing home environment. Child Find The Child Find Program is a component of Early Intervention Services to improve the identification, referral to care and follow-up of infants and toddlers at risk for developmental delay. Child Find works with families and primary health care providers to insure that children have a consistent source of care. Child Find is a safety net to screen children when families cannot be successfully engaged or are unable to access primary health care. The Child Find staff works with health care providers in the community to promote routine developmental surveillance of all at risk children by their primary care providers and monitors the results of these screenings. Child Find attempts to locate children at risk for developmental delays by promoting public awareness of the services available and the developmental needs of children. Preschool Special Education Program Preschool Special Education provides specially planned individual or group instructional services or programs for eligible children, from ages 3-5 years, who have a disability that affects their learning. These services are funded by local municipalities as well as by state funds. A referral can be made to the local school district s Committee on Pre-School Special Education (CPSE). The child will be evaluated and if found to have a disability that may affect his learning, the CPSE will develop an Orange County Community Health Assessment 2010-2013 Section II 3

Individualized Education Program (IEP). This plan may include special education, speech therapy, occupational therapy, assistive technology, physical therapy, parent education and training or counseling services. Physically Handicapped Children s Program (PHCP) PHCP offers financial assistance for medical and surgical rehabilitation to children and young adults to age 21 who have conditions diagnosed as physically handicapped. The program relies on available health insurance benefits as the first step in paying for treatment. Otherwise, treatment is authorized by PHCP Medical Director from state/county funds or Medicaid, provided financial eligibility requirements are met. Children with Special Health Care Needs Program (CSHCN) The Children with Special Health Care Needs Program is an information and referral service designed to assist families of physically challenged or chronically ill children from birth through age 21 years. The staff provides information about programs and resources appropriate for children with special needs. The staff also assists families to access community-based services such as Child Health Plus and Medicaid, Early Intervention, WIC, Developmental Disabilities Service Office (DDSO), and other parent/family support and assistance programs. The Newborn Hearing Screening Program The Newborn Hearing Screening Program provides follow-up through ICHAP/Child Find of infants who have not completed the screening in the hospital or are lost to follow-up by the hospital. Early Intervention provides audiological evaluation and services if needed as well as EI services for all children who have failed the Newborn Hearing Test. Newborn Screening The Newborn Screening Program is designed to provide early diagnosis and medical treatment of serious illnesses that can affect an infant s health. The program provides PHN follow-up for positive or inconclusive screenings to assure that the family secures additional testing and makes appropriate referrals for medical care, insurance, and community/health resources. Adult Polio The Adult Polio program provides financial assistance for the health needs of adults who contracted polio in their youth. Financial assistance is provided for nursing care, medication, durable medical equipment, medical supplies and back-up generators. SIDS-Infant/Child Deaths The SIDS-Infant/Child Deaths Program provides information and referral for families who have an infant or child who has died. Upon notification of a death, the Public Health Nurse sends out a condolence letter to the family listing free support groups and offering a PHN visit. If they agree to a visit, the PHN evaluates the family s needs and determines which services are available to assist the family through this difficult time. If the death is deemed a SIDS death, the PHN completes the referral form and information requested by the New York State SIDS reporting program. The ICHAP/Child Find staff provides SIDS risk reduction information to all families in the ICHAP/Child Find and Early Intervention Programs, as well as at community events, health fairs and community education programs. Despite the decline in rates of SIDS deaths across the country, infant deaths identified as SIDS continue to be attributed to unsafe sleep practices. These include such practices as co-sleeping; prone-sleeping; sleeping on couches or air mattresses; or having pillows, blankets, and toys in the infant's sleep environment. OCDOH has defined the need to expand the Back to Sleep SIDS prevention message and further educate and assist families to make safe sleeping choices for their infants. To this end, the OCDOH Safe Sleep Campaign will be launched in the fall of 2009. This campaign will include distribution of bilingual educational materials and "Safe Sleep" buttons to Prenatal, Pediatric, and Family Practice providers; home health and visitation agencies; Orange County Office for the Aging, Youth Bureau, Department of Social Services and Child Protective Services; and other community agencies. Community Health Outreach Division Community Health Outreach (CHO) is a county and grant-funded Division of the Department of Health. With Orange County s commitment to public health education and NYSDOH grants targeting specific public health issues, the Division strives to improve the quality of life for county residents through a continuum of outreach, education, referral, and case management programs. Services are delivered through offices located in the cities of Newburgh, Middletown, and Port Jervis. The overarching goal of CHO programs is to foster behavior changes to promote health and reduce risk of disease. Public Health Education Public Health Education provides culturally and linguistically appropriate primary prevention and risk reduction education programs as well as health information on a variety of topics. Public Health Educators work with hospitals, health care providers, school districts, businesses, community agencies, local coalitions and the public. Public Health Education programs are provided in such areas as nutrition, physical activity/exercise, obesity prevention, smoking prevention, and oral health education. Additionally, the Public Health Educators work closely with the local media to disseminate public health messages to promote the health and safety of county residents. Healthy Orange In 2006, Orange County Department of Health introduced the Healthy Orange Campaign as a means of addressing rising obesity rates. The latest data from Orange County Community Health Assessment 2010-2013 Section II 4

the National Center for Health Statistics show that 30 percent of U.S. adults 20 years of age and older are obese. The percentage of young people who are overweight has more than tripled since 1980. The Healthy Orange initiative addresses three core health promoting factors - improved nutrition, increased physical activity, and a tobacco free lifestyle - to improve the overall health of Orange County residents. Healthy Orange is the umbrella for a constellation of programs addressing these factors throughout the lifecycle. Healthy Orange Daycares Fit Kids of the Hudson Valley Healthy Orange Worksite Wellness Healthy Orange Seniors Together Eat Well Play Hard Eat Well Play Hard is a community-based program designed to prevent childhood obesity utilizing best practices relative to age-appropriate activity and healthy food choices. Policy change is promoted for childcare, school and after-school programs in the target population of children ages 2 and older and their families in the Newburgh and Middletown school districts. The program's objectives address helping children and their families gain the access, knowledge, attitudes, and skills needed to establish healthy eating behaviors promote or increase physical activity. Strategic Alliance for Health (Building a Healthy Nation) Orange County Department of Health has been selected as part of a new CDC initiative entitled Strategic Alliance for Health Building a Healthy Nation (SAH). New York State was one of two states selected for this program for small cities and rural counties along with Alabama. In turn, the New York State Department of Health selected four counties to participate -- Albany, Broome, Orange, and Schenectady. The purpose of SAH is to create healthier communities through sustainable, innovative community health promotion and chronic disease prevention interventions that utilize policy (laws, rules), system (behavior) and environmental (physical), known as PSE change strategies. The SAH works collaboratively with key partners (a wide range of community leaders, including representatives from education agencies, the health care sector, businesses, the community, and faith-based organizations) in the city of Middletown to develop and implement PSE change strategies. These strategies promote and sustain community-based health promotion and chronic disease prevention programs of sufficient intensity and duration to help achieve the Healthy People 2010 objectives. Lead Safe Orange Lead Safe Orange (LSO) is the umbrella under which our grant-funded programs concerning lead poisoning and lead hazards are coordinated. These programs include the Childhood Lead Poisoning Prevention Program (CLPPP), Healthy Neighborhoods Program (HNP), Primary Prevention Program (PPP), and our collaboration with the county s Office of Community Development on the HUD-funded Lead-Based Paint Hazard Control Program (LBPHC). Through LSO, the outreach and risk reduction efforts of these programs are integrated to intensify and expand efforts to reduce exposure to lead hazards focused on high-risk Census Tracts 3, 4 and 5 in the city of Newburgh and enhance lead poisoning related services throughout the county. Childhood Lead Poisoning Prevention Program The Childhood Lead Poisoning Prevention Program (CLPPP) serves all areas of Orange County. This program tracks all lead testing activity for children in the county between the ages of 6 months and 6 years. Outreach is done via home visits, agency visits, presentations and community events to identify children who need testing and to provide information about health services for children. Case management is provided for lead poisoned children (blood lead levels of > 15 ug/dl) including home visits with the family to teach them about lead hazards, prevention methods, and to ensure medical follow-up for the child. The Environmental Health Division conducts environmental evaluations for the homes of all lead poisoned children. Children with BLL of 10-14 ug/dl receive ongoing monitoring to ensure testing in accordance with NYSDOH guidelines by their medical provider. In addition, risk reduction education is provided to community groups, schools, health providers, landlords and homeowner s associations. Healthy Neighborhoods Program The Healthy Neighborhoods Program (HNP) is a primary prevention program providing public health services to specific geographic areas identified with a high rate of environmental health needs. HNP staff provide education, literature and incentives to residents to assist in identifying lead hazards, methods to control lead hazards, asthma triggers and other environmental health issues. HNP staff also promote tobacco cessation. This program is currently operating in the city of Newburgh. HUD Lead-Based Paint Hazard Control Program This federally-funded program unites two agencies of Orange County Government - the Department of Health and the Office of Community Development. The program has two major preventive goals: to have more children tested for lead poisoning in the county and to market and execute the associated grant/loan programs that work to secure lead safe housing for eligible children and their families. CHO staff conduct door-to-door outreach in the cities of Newburgh, Middletown and Port Jervis. Staff also provide community education in a wide variety of forums, outreach to medical providers, and assist with tenant and property owner applications. The Department coordinates a media campaign to achieve the goals of the program and foster community action regarding this important public health issue. Orange County Community Health Assessment 2010-2013 Section II 5

Primary Prevention Program The NYSDOH-funded Primary Prevention Program (PPP) works within the city of Newburgh s Census Tracts 3, 4 and 5 identifying housing at greatest risk of lead-paint hazards and taking action to make this housing lead safe. This program offers free training through the Office of Community Development on lead awareness and lead safe work practices to contractors, property owners, childcare providers, parents, residents, and landlords. PPP works in conjunction with the Office of Community Development to offer qualified property owners access to funds to make their homes lead safe. Community Health Worker Program The Community Health Worker Program (CHWP) utilizes diverse approaches to outreach, education, referral, and case management throughout the county, concentrating efforts in three targeted zip codes: 12550 (Newburgh), 10940 (Middletown), and 12771 (Port Jervis). The CHWP provides intensive outreach and home visits in these areas to disseminate health information and engage high-risk individuals in early and ongoing prenatal and primary health care. Perinatal care and parenting skill development are cornerstones of the program. In addition, outreach workers provide individual, family and/or group education on disease risk reduction, including safer sex practices, and promote screening and early detection of STDs, HIV, and TB. Case management involves assessing the health needs of not only the client, but the entire family unit including referrals for medical, dental, and family planning services. Tobacco Control Program The Orange County Tobacco Control Program (OCTCP) is based on "Program and Funding Guidelines for Comprehensive Local Tobacco Control Programs" by the National Association of County and City Health Officials and successful strategies from Florida s Comprehensive Plan for Action. This program features six essential elements: Community Programs School-Based Programs Smoking Cessation Counter Marketing Enforcement Surveillance and Evaluation The goal of the OCTCP is to reduce/eliminate tobacco use and its negative effects throughout Orange County. This is accomplished through the efforts of the various programs contained within Community Health Outreach s Tobacco Control Program by: Preventing or delaying initiation of tobacco use by youth; Promoting and providing various free cessation opportunities and modalities to the public; Reducing/eliminating exposure to second-hand or environmental tobacco smoke; Promoting and providing guidance on the development and adoption of tobacco use policy in all sectors of the community; and Educating the public thereby changing the social norm with regard to tobacco use. Tobacco Cessation Orange County offers residents multiple options for no cost smoking/tobacco cessation programs. The aim is to assist smokers in overcoming this addiction to positively impact their health and eliminate exposure to second hand smoke by family members. Adolescent Tobacco Use Prevention Act (ATUPA) ATUPA is a statewide tobacco enforcement program aimed at reducing the use and accessibility of tobacco to youth under 18 years of age. Youth aged 15-17 are trained to conduct compliance checks with Department of Health staff members to ascertain if vendors sell tobacco products to underage youth. Those in violation are provided hearing notices and if found guilty, are fined. Every tobacco vendor in the County receives at least one compliance check yearly. The program also provides tobacco vendor certification classes quarterly at no cost. Youth Action Program/Reality Check Reality Check is a youth led movement (ages 13 18) within the New York State Tobacco Control Program that is committed to exposing the manipulative and deceptive marketing practices of the tobacco industry. Reality Check initiatives include: Changing the social norms regarding tobacco by de-normalizing and de-glamorizing tobacco, tobacco use, and the tobacco industry. Increasing the number of stores that limit or eliminate tobacco advertising and promotion at the point-of-sale. Increasing the number of community events and organizations that refuse tobacco company goods, services, and financial support. Increasing the number of movies rated G, PG, and PG-13 that do not include smoking and tobacco imagery. Increasing the number of periodicals that eliminate tobacco advertisements. Promoting policy change at the local and state level. Tobacco Free Schools Program Tobacco Free Schools was created to increase the capacity of schools to implement effective tobacco-free policies that are in compliance with state and federal law and to establish a minimum standard in New York Schools Tobacco Policy. The school policy coordinator provides schools with expertise, assistance, tools and resources to: Assess current tobacco policies and tobacco use in their schools; Develop effective tobacco-free school policies and procedures; Develop an implementation and enforcement plan for the tobacco-free policy; Orange County Community Health Assessment 2010-2013 Section II 6

Evaluate the effectiveness of the policy and its implementation. Program staff assist schools to implement their tobacco free policies, enforce the policy with in-school alternatives to suspension, and communicate the policy to the public. Resources based on current research are provided as well as staff and student training. Lyme Disease Prevention Program The Lyme Disease Prevention Program conducts education and surveillance in Orange County. The Senior Public Health Educator and Community Health Worker meet with the public and health care providers in accessible venues to provide risk reduction education. This program assists in the identification of ticks and provides referrals for medical care and information. The program works with the NYS Arthropod Disease program at Hudson Valley Community College to conduct biogeography studies of ticks in the county. Migrant Health Services Program The Migrant Health Services (MHS) Program provides outreach and education services to migrant farm workers in Orange County to reduce the risk of contracting communicable and infectious diseases and improve occupational health and safety. This is a collaborative service between Orange County Department of Health and the Hudson Valley Migrant Health Program of the Hudson River Community Health Center based in Pine Island. The primary focus areas of the program are TB, HIV, STD, and injury and substance abuse prevention. West Nile Virus Surveillance and Education Program Since West Nile was first discovered in 1999, Orange County has had a program in place to collect mosquitoes for testing by the NYSDOH Wadsworth Laboratory. The county has entered into a contract with Orange County Community College to collect mosquitoes from high-risk areas for testing. When positive reports are received, risk reduction education is intensified. Press releases are issued to alert the communities affected to take extra precautions. Every spring a prevention campaign is initiated to make residents aware of the actions they should take to help prevent mosquito infestation. Environmental Health Division Environmental Health is divided into two operating Bureaus, the Bureau of Sanitary Engineering and the Bureau of Sanitary Control. The Bureau of Sanitary Engineering is responsible for two major programs - plan review and public water supplies. Engineers also provide technical assistance, primarily in terms of water and sewage, for the Bureau of Sanitary Control s programs. The Bureau of Sanitary Control is responsible for 10 programs, the largest of which is the food service establishment program, all of which come under the supervision of New York State Department of Health s Bureau of Community Environmental Health and Food Protection. In addition, the Bureau conducts a local school inspection program, provides a tick identification service and collaborates with the Public Health Nursing Division in managing the Department s Rabies Control Program. Plan Review There is a self-imposed goal of a maximum 30-day turnaround in the plan review program to provide rapid service to the public. Plan reviews include residential subdivisions, individual sewage disposal systems (at permitted facilities and as requested by municipalities, and that are required to be submitted by the State Sanitary Code), swimming pools, in addition to public water supply improvements. In 2008, there were 164 plan reviews of residential subdivisions and 36 approvals representing approximately 395 residential building lots. In the course of reviewing subdivisions, program staff evaluate whether there is an acceptable means of sewage disposal for each lot and an acceptable means of providing water of adequate quality and quantity. In 2008 there were 216 reviews and 71 approvals of public water supply improvements. Water Program OCDOH is the regulatory agency responsible for approximately 169 community water supplies and 331 non-community water supplies. All community supplies and a number of non-community water supplies fall under the Bureau of Sanitary Engineering. One of the most important functions in protecting the public health is the monthly microbiological sampling of the County s community water supplies. This sampling is performed by two public health technicians and results in a determination if there is an immediate public health threat. The technicians with the guidance from public health engineers can often institute an immediate repair/response by the water supplier and/or protect the consumers with a boil water notice within the shortest possible time. All public water supplies are inspected at least once per year by either a public health engineer or technician. By doing so, program staff not only spot violations of the Sanitary Code but also consult with the water operators and make recommendations for improvements precluding some emergencies. Annual water supply inspections are often the impetus to construct major water supply improvements. These detailed inspections have permitted the program to work closely with water systems and the NYSDOH regarding the allocation of the State Revolving Fund (SRF) money to Orange County. Regarding the regulatory responsibility to see that all water systems perform the required chemical monitoring, reports, operators, etc., the program has developed and depends on an extensive computerized water monitoring program. Presently, we are notified of petroleum and other hazardous chemical spills by the New York State Orange County Community Health Assessment 2010-2013 Section II 7

Department of Environmental Conservation at a rate of approximately one and one-half per day. The NYSDEC and/or water suppliers are notified of any actions needed to protect public water supply sources on an as needed basis. Inspection and Permitting Programs Food Service Establishments - The Division inspects and permits 2,104 food service operations. Using menu and recipe reviews and noting the populations they serve, facilities are classified in respect to their potential for causing foodborne illness. Facility inspections are scheduled depending upon risk category (i.e., the higher the risk, the more frequent the inspection) so that more time can be spent educating operators in safe food handling practices. The Division plays an integral part in the Department s foodborne disease surveillance and investigation of all suspected foodborne disease incidents/outbreaks. The Division of Environmental Health is charged with the responsibility for environmental issues (food preparation review and collection of food samples) while the Division of Public Health Nursing is responsible for the epidemiologic investigation relating to the suspected illness (signs, symptoms, incubation period, duration of the illness, collection of clinical specimens, etc.). The Department s foodborne disease surveillance officer is responsible for incident coordination (within the Department and with appropriate State Health Department and/or Department of Agriculture and Markets personnel) and for the submission of a report of investigation findings and recommendations to the NYSDOH. Children s Camps The inspection and permitting of children s overnight and summer day camps continues to be one of the Division s most important seasonal programs. Camps are checked to make sure physical facilities are safe and that supervision is adequate. Reportable camp injuries, illnesses and child abuse allegations are investigated by Division staff. Ninetysix (96) camps operated during the 2008 season. The program keeps expanding into safety considerations in addition to traditional health regulation as we become involved in archery, rifle ranges, rope courses, and waterfront activities, etc. Migrant Farmworker Housing Housing facilities for migrant farmworkers are inspected prior to occupancy and while in use to ensure that the water supply is safe, sleeping, lavatory, shower, heating and kitchen facilities are adequate and no fire hazards exist. Thirteen (13) migrant farmworker housing facilities operated during 2008. Swimming Pools and Bathing Beaches Public swimming pools, wading pool, spa pools and bathing beaches are inspected and permitted by the Division to assure that the facilities meet sanitary and safety provisions of the State Sanitary Code. Reportable injuries and illnesses are investigated by Division staff. In 2008, 205 public swimming facilities operated in the county. Temporary Residences Hotels, motels, bungalow colonies and campsites are inspected and permitted under this program. Fire safety, housing maintenance, water supply, sewage disposal, bathing, swimming and lavatory facilities are the main areas of concern in this program. In 2008, 109 temporary residences operated in the county. Schools and Day Care Centers The Division s school and day care center inspection programs encompass many areas of sanitation and safety concerns from water supply, lavatory and locker room sanitation to shop and playground safety. Although only food service and swimming facilities are required to be permitted by the Department, recommendations are made to facility operators on all areas of their operation. All facilities on record (178 schools and 47 day care centers) are scheduled to be inspected at least once each year. State and Local Institutions Food service and swimming facilities at state institutions and institutions licensed by State agencies (Mental Hygiene, Social Service, Youth Bureau, etc.) are inspected annually by Division staff. Fourteen (14) institutions currently exist in the county. Mobile Home Parks Sanitary facilities and fire safety are the primary concerns of this program. Fifty-four (54) mobile home parks are inspected and permitted annually. Smoking Restrictions The Division enforces the provisions of New York s Clean Indoor Air Act in indoor areas open to the public. Food service establishments are checked for compliance with the Act on a regular basis and all other public areas (retail stores, public buildings, worksites, etc.) are surveyed in response to citizen complaints. Lead Poisoning Prevention Environmental lead evaluations of housing facilities are conducted by Division staff upon referral by the Department s Childhood Lead Poisoning Prevention Program. Increased awareness and cooperation by building owners in conducting remediation have led to a steady decrease in the number of cases which need to be referred for enforcement action. Rabies Control The Division of Environmental Health collaborates with the Division of Public Health Nursing in managing this program. Orange County was one of the first counties to become affected by the raccoon rabies epizootic when it entered New York State from Pennsylvania in 1990. The disease has continued to be endemic in wild animal populations (especially raccoons and skunks) and as such has been a constant threat to domestic animals and county residents. The State Health Department s amended guidelines for managing indoor bat encounters has also prompted the Department to intensify its efforts to educate the public in respect to bat rabies. Orange County Community Health Assessment 2010-2013 Section II 8

The Division of Environmental Health is responsible for preparing and submitting animals to the NYSDOH s Rabies Laboratory, counseling and educating local government officials, animal control officers, and the general public on the management of domestic animal exposures to rabies. The Division has jointly sponsored free pet vaccination clinics with municipalities for Orange County dog and cat owners annually since 1989. State regulations require at least one clinic to be held every four months. Nuisances Complaints made by the public in relation to various environmental concerns (e.g., sewage, garbage and rodents) are investigated by Division staff. Lyme Disease A tick identification service has been provided by the Environmental Health Division for several years as an adjunct to the Department s Lyme Disease Prevention Program. Although ticks are not tested for presence of the Lyme disease bacterium, this service provides the individual with information regarding the tick which they can share with their physician if Lyme disease treatment is being considered. Office of Public Health Emergency Response The Office of Public Health Emergency Response (OPHER) provides services and has the responsibility for the coordination of all activities relating to the preparedness and response to a public health emergency in Orange County. These services are provided before, during, and after a public health emergency. OPHER is tasked with the development and the maintenance of the Public Health Emergency Response Plan (PHERP), an annex to Orange County s emergency response plan. The PHERP provides response guidance that applies to most situations, such as communications, information and notification protocols. The PHERP also includes event-specific guidance on incidents such as chemical, radiological, and bioterrorism incidents, and pandemics. The OPHER regularly conducts joint planning sessions with local, state, and federal law enforcement agencies, Fire, Emergency Medical Services, the Orange County Department of Emergency Services, NYSDOH, NYS Emergency Management Office, local hospitals, the US Military Academy at West Point, and neighboring county public health and emergency response agencies. Multiagency coordination greatly enhances Orange County s ability to respond to a public health emergency. In addition, emergency plan development guidance is routinely provided to school districts, home health care companies and other businesses or institutions looking to coordinate pandemic flu or continuity of operations planning (COOP) with the county. OCDOH has designed and implemented several epidemiological surveillance systems to detect a possible outbreak of disease in Orange County. School surveillance is conducted in several sentinel public school districts in the county. This surveillance measures absenteeism rates in students and faculty to determine if there is an unusual absenteeism rate that may be due to an emerging disease outbreak. OPHER also conducts surveillance of 911 calls made in the county. The data from the 911 calls is filtered to determine how many people are requesting assistance due to illness each day. Non-illness related 911 calls are filtered out. In cooperation with local hospitals and the NYSDOH, daily emergency room chief complaint surveillance is now being monitored electronically. The Office also reviews data from the University of Pittsburgh s Real-time Over the Counter Data System (RODS) system. RODS provides the OPHER with data concerning the purchase of over the counter medicines in Orange County to determine if an unusual number of residents are self-medicating in response to a possible outbreak. The OPHER also has the responsibility of managing the Medical Reserve Corp. (MRC) which is a group of credentialed volunteers from various medical backgrounds. These volunteers are trained to work with the OCDOH Nurses in times where additional trained medical staff may be needed. A volunteer coordinator oversees this program to insure that training, current certifications and database contact information are updated. There are currently 265 credentialed volunteers in the Orange County MRC. The emergency communications plan within the OCDOH has been coordinated with the Department of Emergency Services to ensure interoperability between the OCDOH and other emergency response organizations. Every thirty days the OPHER conducts communications drills within the OCDOH and with our partner organizations to ensure that the OPHER has the most current contact information possible. Training is essential to any effective emergency response. The OPHER has the ability to provide training directly or facilitate the training of Orange County first responders by professional instructors from outside OCDOH. Orange County Community Health Assessment 2010-2013 Section II 9

SECTION TWO: LOCAL HEALTH UNIT CAPACITY PROFILE B. CURRENT SERVICE TRENDS AND WORKLOADS Administration There has been an increased emphasis on local health planning focused on Bioterrorism/Public Health Emergency Preparedness and Response (BT/PHEPR), since the tragedy of September 11, 2001 and recent advancement of the Pandemic Alert Stage by the World Health Organization in response to the novel Influenza A H1N1 outbreak. Support for Public Health Emergency planning also represents one of the few new funding resources for county health departments throughout the state. All other Community Outreach Grant funding has remained flat or decreased at a time when the preventive and primary health care needs of high risk target groups in the county continue to increase. The requirement for all staff to train for PHEPR has not been entirely compensated by grant funds, placing added demands on limited staff resources. However, BT/PHEPR funding has permitted Orange County to employ a part-time nurse epidemiologist to spearhead local collection, centralization, and analysis of health-related data, including that pertaining to disease outbreaks. OCDOH collects data for comparative purposes and actively monitors trends in disease incidence, prevalence, and vital statistics. This funding has also allowed OCDOH to improve our communications and technological capabilities, including increasing use of communication devices such as blackberries, cell phones, satellite phones and laptops, to allow mobility in operations and the development of redundant communication systems. Concern about public health emergencies has facilitated increased cooperation among the health department and first responder agencies such as law enforcement, hospitals, EMS, and fire. Collaborative planning meetings, exercises and drills are held regularly. In addition, new active surveillance systems have been facilitated, notably school (student and teacher) absenteeism, ER syndromic surveillance, 911- call surveillance and review of RODs data. Daily hospital calls, instituted when West Nile was the most prominent public health concern, continue as they enable increased personal communication with Infection Control Nurses and hospital Emergency Department staff, which remains invaluable. The initial focus on BT preparedness and response has expanded to an all-hazards approach, for more comprehensive preparedness planning, including that for Pandemic Influenza. The continued emphasis on training our public health workforce in BT/PHEPR diverts staff time available in less emergent areas - such as risk reduction for chronic and communicable diseases - which are of paramount importance to improving the health of county residents. Engaging all health department staff in preparedness exercises and drills places increasing demands on finite personnel resources in a rapidly growing county. The Early Intervention and Preschool Programs continue to present great fiscal challenges to the Department. Continuing population growth in the county intensifies the need for services and service coordination without adequate funding to support the compensatory increase in staffing. As in other counties, the annual budget for these programs dwarfs the combined budget for all other public health activities. Public Health Nursing Division CHHA/LTHHCP As shown in Figure 1, the major diagnostic categories in home health patients for the past two years reflect musculoskeletal, cardiovascular, skin/subcutaneous tissue and respiratory disorders prevalent in the predominantly elderly population served by these programs. Figure 1: CHAA/LTHHCP MAJOR DIAGNOSTIC CATEGORIES BY YEAR, 2007-2008 300 250 200 150 100 50 0 Skin/Subcuteoneous Tissue Circulatory System - Cardio MAJOR DIAGNOSIS Musculoskeletal Respiratory System Figure 2: CHHA/LTHHCP VISITS BY YEAR AND DISCIPLINE, 2004-2007 DISCIPLINE 2004 2005 2006 2007 Nursing 13,060 11,668 11,330 11,557 Physical Therapy 3,334 2,531 2,114 2,112 Occupational Therapy 241 360 345 502 Speech Therapy 219 98 8 7 Medical Social Worker 1,183 1,534 1,300 1,015 Nutritionist 153 340 276 203 Home Health Aide (HHA) Personal Care Aide (PCA) 7,387 6,158 5,755 3,513 19,068 17,885 16,032 11,617 2007 2008 As shown in Figure 2, since 2004, there has been an overall decline in nursing, PCA, and HHA visits. This is Orange County Community Health Assessment 2010-2013 Section II 10

due to the provision of home health services in the county by other agencies one CHHA administered by Good Samaritan Hospital in Rockland County, and one private CHHA with offices in the cities of Newburgh and Middletown. OCDOH continues to be the primary home health service provider for the uninsured. Tuberculosis Control Program The Tuberculosis Control Program clinics serve a mainly foreign-born population clustered in the cities of Newburgh and Middletown. Approximately 85% of latent TB infection (LTBI) patients are Spanish speaking. Of the 45 persons receiving medication in 2008, 13 or 28% were under the age of 18. Individuals identified as positive for latent TB infection in private medical practice and school testing are referred to Health Department clinics for treatment and management. Over the last five years OCDOH has seen a decline in the number of children receiving treatment for LTBI through our clinics. This is likely due to an increase in children insured under Child Health Plus and physicians treating their patients privately. OCDOH TB Program continues to receive referrals from local clinics and schools. A Summary of TB Program tests and cases from 2004-2008 is provided in Figure 3. Figure 3: TUBERCULOSIS CONTROL PROGRAM TESTS AND CASES, 2004-2008 2004 2005 2006 2007 2008 5-Year Average TB cases 9 3 4 8 8 6.4 Mantoux tests 635 616 548 826 795 684 Positive tests 44 40 57 54 12 41.4 LTBI therapy 118 119 106 89 45 95.4 Therapy completed (%) 75 100 83 76 48 76.4 STD/HIV Program The OCDOH has been providing STD testing and treatment for reportable and non-reportable STDs at the Newburgh STD Clinic for over 30 years. OCDOH added a weekly STD Clinic in Middletown in 2002. Figure 4 shows the upward trend in total annual visits for these clinic sites from 2004-2008. Figure 4: TOTAL ANNUAL VISITS, OCDOH STD CLINICS, 2004-2008 800 700 600 500 400 300 200 100 0 2004 2005 2006 2007 2008 YEAR STD STD Communicable Disease Investigations As shown in Figure 4, the annual number of Chlamydia cases has increased considerably since this STD became reportable in NYS in 2000. In fact, Chlamydia currently ranks first in the number of cases reported among all reportable communicable diseases in Orange County. All cases are followed for therapy monitoring. Priority Chlamydia cases are assigned to Public Health Investigators (PHI) for partner follow-up. In contrast, reported cases of Gonorrhea have remained relatively constant from 2000 to 2008. All Gonorrhea cases are assigned for PHI follow-up. OCDOH receives approximately 400 Reactive Syphilis Serology Reports each year. All laboratory reports are reviewed closely to determine if they represent untreated Syphilis, previously treated Syphilis, or false positives. Untreated Syphilis cases are assigned for PHI follow-up. Less than 10 patients per year have been diagnosed with Early Syphilis (Syphilis infection of less than 12 months duration) in the county. Figure 5: SEXUALLY TRANSMITTED DISEASE CASES BY YEAR, 2004-2008 1000 900 800 700 600 500 400 300 200 100 0 582 686 605 720 878 177 113 141 119 168 6 1 2 8 9 2004 2005 2006 2007 2008 YEAR Chlamydia Gonorrhea Early Syphilis HIV Partner Assistance Program (PNAP) HIV became a reportable disease in 2000. Each case of HIV is assigned to a PHI for PNAP interview and investigation. Figure 6 shows the number of cases assigned for PNAP investigation and the number of partners assigned for HIV notification from 2004-2008. Figure 6: HIV CASE INTERVIEWS AND PARTNERS IDENTIFIED FOR NOTIFICATION, 2004-2008 60 50 40 30 20 10 0 52 50 18 21 2004 2005 2006 2007 2008 YEAR 47 33 44 29 37 25 Unique HIV Cases for PNAP Interview HIV Partners for notification Orange County Community Health Assessment 2010-2013 Section II 11

HIV Counseling and Testing Clinics HIV Counseling and Testing Clinics have been held in both Newburgh and Middletown since 1987. Figure 7 shows the number of HIV tests performed from 2004 to 2008. OCDOH began Rapid HIV Testing in 2006 which lead to an increase in the number of patients tested. In 2005 and 2006 the STD Clinic Nurses received HIV Counselor Training. Each patient now receives HIV pretest counseling as part of their STD Clinic visit. Figure 7: HIV CLINIC VISITS BY YEAR, 2004-2008 800 700 600 500 400 300 200 100 0 2004 2005 2006 2007 2008 YEAR Hepatitis Vaccines OCDOH began administering the Hepatitis vaccine in October 2007 at STD Clinics. Each patient is offered the Hepatitis B vaccine, Hepatitis A vaccine, or Twinrix vaccine (combined Hepatitis A and Hepatitis B vaccines). The total number of patients vaccinated for Hepatitis in 2008 was 45. Immunization Program Figure 8: IMMUNIZATION PROGRAM VACCINATIONS, 2004-2008 YEAR 2008 2007 2006 2005 2004 0 250 500 750 1000 1250 1500 1750 2000 2250 2500 2750 3000 NUMBER OF VACCINES ADMINISTERED Children Flu HIV Pneumonia Children s immunization clinics are held monthly or semi-monthly, by appointment, in seven locations in the county. The clinics are available to residents from two months of age through college. In 2007 the NYS requirement of Tdap for 7 th grade entry was implemented. In accordance with recent CDC guidelines, influenza vaccine is now provided in immunization clinics for infants and children ages 6 months 18 years of age. Service demands are expected to increase in the future as more physicians endorse the recommendation. Flu vaccination clinics are conducted each fall for adults ages 19 and over. The CDC recommendation for annual influenza vaccination in adults of all ages is projected to cause an increased demand for vaccination services. Pneumoccocal vaccine is available at flu clinics for adults 65 years and over. This vaccine is administered only once in this age group and therefore the number of potential vaccinees decreases yearly as this population becomes increasingly immunized. Adult and travel clinics, established in 2003, provide all vaccines required for foreign travel as well as meningitis vaccine for college entrance and preexposure rabies for veterinary students and animal control and shelter employees. WIC Program In FY 2008-2009 the OCDOH WIC Program s approved caseload was 7,469 pregnant, breastfeeding, postpartum women, infants and children under the age of five. Our caseload remained stable due to the continued need for service in the county. Intervention Services Division Early Intervention Figures 9-11 address the growing service trends in this program: Early Intervention and Preschool Special Education contains the numbers of clients since 1998 per school year with the cost and the percentage increase. Early Intervention Referrals and Active Cases contains the number of clients from 2003-2008. Figure 9: EARLY INTERVENTION CLIENTS AND COSTS, 2003-2008 Year Number of Clients % Increase from previous year Total Cost all Payers Average Cost Per Child 2002-2003 1,707 11% $ 7,831,808 $ 4,588 2003-2004 1,711 0.2% $ 8,035,308 $ 4,920 2004-2005 1,696 0% $ 8,429,389 $ 4,970 2005-2006 1,911 12.6% $10,066,917 $ 5,268 2006-2007 2,047 7% $ 10,495,053 $ 5,127 2007-2008 2,207 7.8% $ 10,857,586 $ 4,920 Figure 10: PRESCHOOL SPECIAL EDUCATION CLIENTS AND COSTS, 2003-2008 Year Number of Clients % Increase from previous year Total Cost all Payers Average Cost Per Child 2003-2004* 1,460 9% $15,243,473 $10,441 2004-2005 1,543 5% $16,642,748 $10,786 2005-2006 1,499-2% $17,015,869 $11,351 2006-2007 1,581 5% $18,725,098 $11,844 2007-2008 1,649 4% $21,448,013 $13,031 *Through March 31, 2004 n/a Reliable data are not available due to a change in computer data management systems. Orange County Community Health Assessment 2010-2013 Section II 12

Figure 11: EARLY INTERVENTION AND ICHAP REFERRALS AND ACTIVE CASES Referrals Per Year, 2003-2008 Year ICHAP Referrals EI Referrals Total 2003 406 897 1,303 2004 487 795 1,282 2005 447 978 1,425 2006 484 1,026 1,510 2007 484 1,109 1,593 2008 487 1,238 1,725 Active Cases* Per Year, 2003-2008 Year ICHAP Active Cases EI Active Cases 2003 764 1,603 2004 980 1,506 2005 808 1,685 2006 802 1,877 2007 798 1,964 2008 769 2,176 *An active case is defined as any child who has at least one EI or ICHAP service in the year In 2008 there were 2,540 home visits made by the Initial Service Coordinators to EI families. The need for additional staff became evident as the current caseload for each service coordinator was between 170-190 clients vs. the state recommendation of 25-50. The county approved 8 new ISC positions in 2008 which will bring the average caseload to 100 or fewer. There is also a need for additional providers for services in demand, especially speech pathologists, and for providers of all disciplines to work in difficult to serve areas - inner city, rural, and less accessible areas of the county such as Highland Falls (this applies to all programs). The need for providers is evidenced by waiting lists which result in service delays. Child Find The Child Find caseload per year is included in Figure 11. To enhance program efficiency and comprehensive pediatric care, there is need for primary health care providers to universally conduct developmental screenings on children during their well-child visits. Preschool Special Education Program The Preschool Special Education Program caseload for 1998-2004 is provided in Figure 8. In addition, approximately 50-65 Committee on Preschool Education (CPSE) meetings are held per month. Each meeting has 10-12 children reviewed. Due to staffing constraints, the county is represented at only 30-40% of those meetings. There is also a need for additional providers for related services in demand, especially speech pathology. The need for providers is evidenced by waiting lists (sometimes as long as 2-3 months) which result in service delays. Physically Handicapped Children's Program An average of 50 children per year are assessed by the Diagnostic and Evaluation Program. Approximately 80 children receive treatment through PHCP payment per year, primarily for orthodonture. Children with Special Health Care Needs An average of thirty-seven families of children are served with information and referral services per calendar year. Newborn Hearing Screening Program Twelve children were referred and received services in 2007-2008. Newborn Screening Program One hundred and seventy-four children were referred and received services in 2007-2008. Adult Polio One client is presently served through the Adult Polio Program. SIDS-Infant/Child Deaths Twenty-eight families of children were referred and received services in 2007-2008. There is a need for more timely receipt of death certificates to enable earlier contact with families. Childhood Lead Poisoning Prevention Program Eighty-three lead chart reviews were conducted in 2007-2008 by the PHN in collaboration with the Community Health Outreach Division s CLPPP. Community Health Outreach Division The following highlights major trends in services and staffing issues by program area. Public Health Education Health Education for the public is ongoing throughout the year, including individual and group services. This includes culturally and linguistically appropriate Information on many health topics, including NYS Prevention Agenda Health Priorities. CHO staff participate in over 30 community events each year as part of preventive health education services. Primary prevention is a major focus of our community programs and services since our target population has limited access to preventive education and health care. Public Health Educators, with specialized training in disease prevention and health promotion, work collaboratively with diverse community and faith-based organizations to provide educational programs and services to vulnerable populations. Healthy Orange According to the county s 2003 BRFSS results, over 60% of county adults ages 18 and over are overweight or obese (BMI > 25). Being overweight or obese increases the risk of developing metabolic syndrome and chronic diseases such as asthma, hypertension, Type 2 Orange County Community Health Assessment 2010-2013 Section II 13

diabetes, cardiovascular diseases, certain types of cancer, and musculoskeletal disorders. To address these health concerns in the adult population, Healthy Orange implemented several worksite wellness programs focusing on healthy eating and activity practices. Healthy Orange Worksites promotes physical activity at work though walking events and walking clubs for employees. This initiative provides free heart risk assessments biannually to employees in partnership with Orange Regional Medical Center s Healthy Heart Program. Since 2006, Healthy Orange has implemented programs in 36 local worksites including County Government, SUNY Orange, Genpak, AMPAC, as well as many schools and other businesses. Healthy Orange oversees a grant program to local schools called Fit Kids of the Hudson Valley (FKHV). Fit Kids addresses the rising obesity epidemic in schoolage children through policy and environmental changes at the individual school level. Fit Kids is presently working with 18 individual schools in the county. Each school has completed the CDC School Health Index to identify areas for improvement in wellness policies, formed wellness committees, and provided activities such as increasing access to whole grain products and fresh fruits and vegetables in the cafeteria, decreasing foods with low nutritional value, increasing physically active extracurricular options, and adding more physical activity into students school day (i.e. walking clubs, yoga classes) to support policy and environmental changes. Fit Kids also provides education and activities for parents and staff. Eat Well Play Hard During 2007-2008, the Eat Well Play Hard (EWPH) Health and Wellness Coordinator worked with school districts in the cities of Middletown and Newburgh to promote policies and practices for increased consumption of fruits and vegetables, low-fat milk and dairy foods, and increased physical activity for elementary and middle school students. The EWPH Health and Wellness Coordinator attended regular health and wellness meetings at both districts throughout the year and promoted healthy fundraising policies, food service promotion of fruits and vegetables and healthy school celebrations. A low-fat milk campaign was conducted during 2008 in Middletown and Newburgh communities. Ads were placed in local newspapers promoting the benefit of low-fat milk. Point-of-Purchase health information was disseminated at major supermarkets and neighborhood stores in Middletown and Newburgh. The EWPH Health and Wellness Coordinator began working with childcare centers in Middletown to develop best practice policies to promote increased consumption of fruits, vegetables, low-fat milk and increased physical activity for young children. Strategic Alliance for Health (Building a Healthy Nation) The SAH is an essential part of Healthy Orange s Fit Kids of the Hudson Valley and Eat Well Play Hard Programs. At the end of the first year of this program, a full-time Senior Public Health Educator position will be created to implement and evaluate the program s change strategies. This person will supervise the work of the existing Health and Wellness Coordinators and Public Health Educators included in the initiative. SAH will conduct a Community Assessment in the Enlarged City School District of Middletown and city of Middletown applying the CDC CHANGE tool to five agencies in each of the following categories: community, health care providers, community-based institutions, schools and worksites. Each CHANGE tool examines physical activity, nutrition, tobacco use, chronic disease management and leadership. Lead Safe Orange With the tremendous growth in the number of Hispanic/Latino immigrants in our county, the LSO program has enhanced outreach and engagement efforts with Spanish speaking populations through our bilingual staff to inform at- risk groups of available lead poisoning prevention services and assist in the application process for HUD remediation/abatement loans. This has improved communication with landlords and property owners to work toward the reduction of lead-burdened residences throughout the county. Lead Safe Orange has strengthened partnerships with three divisions of the OCDOH and with other county departments (Department of Social Services and Office of Community Development) within the county system and municipal agencies (Cities of Newburgh and Middletown) on this critical public health issue. Childhood Lead Poisoning Prevention Program CLPPP employs two Community Health Workers (CHW) - one full-time and one part-time (.70 FTE). With the largest caseload of lead-burdened children per capita in the Hudson Valley Region, Orange County has a need for 2 FTE CHW case managers. CLPPP makes at least one outreach and education visit to each pediatric provider within Orange County every year. The city of Newburgh consistently has the highest lead testing rates; testing rates in Middletown and Port Jervis are considerably lower. CLPPP staff conduct outreach efforts including numerous lead blitzes, canvassing neighborhoods with lead poisoning prevention information, communicating the importance of testing, and conducting health fairs and health provider visits. In spite of these efforts, testing rates in Middletown and Port Jervis have not improved significantly. Although NYS Public Health Law requires all children receive lead testing at one and two years of age, the number tested in Orange County remains at approximately 60%. Orange County Community Health Assessment 2010-2013 Section II 14

Healthy Neighborhoods Program HNP employs two.8 FTE CHWs. HNP staff work with tenants in the city of Newburgh to reduce lead hazards, asthma triggers, tobacco use, improve indoor air quality and the general quality and safety of their homes through a healthy homes model of outreach and education. HNP staff visit residences based on street outreach and referrals and concentrate efforts on Census Tracts in the east end of the city; these services are also provided in other areas. HNP works closely with the Newburgh Office of Code Compliance to help ensure residents are living in an environment that meets health and code standards. HUD Lead-Based Paint Hazard Control Program This grant funds one full-time Public Health Educator and one full-time CHW. Since 42% of housing units in Orange County were built before 1960, the LBPHC Program has made a substantial impact in providing lead education and hazard reduction information throughout the county, with a concentrated effort in the cities of Middletown, Newburgh, and Port Jervis. Program staff continue to work on mass mailings to property owners, focusing on Newburgh and Port Jervis. Staff also participate in assisting in the completion of and collection of lead remediation and abatement applications from property owners and tenants. The bilingual abilities of program staff are extremely important in these activities. During 2008, LBPHC staff concentrated their outreach efforts within the city of Newburgh, specifically Census Tracts 3, 4 and 5. The Office of Community Development portion of this program has a work plan goal of completing 200 housing units. To help accomplish this, Community Health Outreach efforts involve collaboration among PPP, HNP, CLPPP and LBPHC and have included door-to-door outreach, street outreach, partnerships with other community based organizations in the target area, letters to property owners, newspaper ads and community events. Lead safe work practice training has also been provided for property owners through our association with the Office of Community Development. Primary Prevention Program (PPP) PPP employs one full-time Public Health Educator, one full-time Public Health Sanitarian and one full-time CHW. The PHE and CHW are bilingual. The city of Newburgh currently has 84% pre-1970 housing units. Since this has produced a high incidence of lead poisoning in this area, Orange County s Commissioner of Health has designated Census Tracts 3, 4 and 5 as areas of high risk. PPP s goal is to identify and reduce lead hazards through preventive education and intervention, before children become lead poisoned. Currently, PPP staff work collaboratively with HNP staff to conduct healthy home and lead inspections. Outreach efforts are coordinated among PPP, HNP, CLPPP and LBPHC personnel and lead safe work practice trainings are provided for property owners at our Newburgh site to make these accessible to local property owners and lead abatement/remediation contractors. Community Health Worker Program (CHWP) Countywide there has been tremendous growth in the number of Hispanic/Latino immigrants, mainly from Mexico and nations in Central and South America. Of all demographic trends, this has had the greatest impact on services. To meet this growing demand, CHWP now has two designated bilingual CHW positions, one servicing the 12550 (Newburgh city) area and the other in the 10940 (Middletown city) area. Program staff frequently encounter women without medical or prenatal care therefore it is imperative for early intervention to occur to ensure referrals to such entitlement programs as the Prenatal Care Assistance Program are made. Currently, CHWP receives on average 20 referrals a month. However, due to the transient nature of the population that this program serves, there are significant challenges to engaging women in program services long term. CHWP is comprised of 3.2 grant funded positions as well as two county funded positions. Tobacco Control Program OCDOH s Tobacco Control Program (TCP) works to move county residents and businesses toward environmental and policy change regarding tobacco use in various settings, including schools and municipalities. A large part of our work involves prevention of smoking initiation in youth, including enforcement of prevention of sale of tobacco to minors. Several programs exist under the umbrella of the Tobacco Control Program to help meet these objectives. TCP staff conduct outreach in Orange County communities to encourage and support residents to establish tobacco free lifestyles. In order to accomplish this, the OCDOH TCP offers a variety of free smoking cessation methods and promotes Smoke Free Homes and Cars Campaign along with Smoke Free Playgrounds through a Young Lungs at Play Initiative. Our various programs participate extensively in known Tobacco Prevention Campaigns like Kick Butts Day, World No Tobacco Day, and the Great American SmokeOut. Tobacco Cessation Access to the Health Department s free smoking cessation programs has increased. It includes cessation provided by three individual contractors and one conglomerate contractor (clinic). Free Behavior Modification Classes are conducted throughout our communities by the TCP s Public Health Educator. Adolescent Tobacco Use Prevention Program (ATUPA) Community Health Outreach is making a concerted effort to take this program from compliance only to a more comprehensive program that can work closely with vendors and youth to decrease the sale of tobacco products to minors in Orange County. With this in Orange County Community Health Assessment 2010-2013 Section II 15

mind, the county has become a certified trainer through NYSDOH and offers free vendor sales certificate training programs quarterly to any owners or sales staff of tobacco vendors in Orange County. Orange County provides the in-kind services of an Assistant County Attorney who handles all legal issues and represents the county during violation hearings. The program contracts with an outside attorney who acts as hearing officer during administrative hearings. Tobacco sales inspections were conducted in over 400 stores in the county by youth compliance workers. There has been a decrease in the number of violations over the past 5 years (see Figure 12). The total number of compliance checks often exceeds number of total facilities due to the program conducting compliance checks by minors, compliance checks by adults and second inspections (with minor) on facilities with previous sales. Figure 12: ATUPA 5 YEAR COMPARISON, 2003-2008 Grant Year 10/03 9/04 10/04 9/05 10/05 9/06 10/06 9/07 10/07-9/08 Total # of Facilities 499 469 443 430 409 N/A # of Inspections 565 520 520 617 409 2,631 # of Sales 128 48 33 48 39 296 Youth Action Program/Reality Check Reality Check works with municipalities, school boards, community-based organizations and community members in Orange County to eliminate the amount of exposure to tobacco advertising by youth. Reality Check staff and youth educate government officials and policy makers at the state and local level to increase visibility of program successes and build support for Reality Check initiatives. Reality Check staff and youth advocates work with organizational decision makers to adopt policies and resolutions to prevent and reduce tobacco use and tobacco advertising. This builds support among community members for tobacco control action, stimulates community demand for tobacco control policies, and demonstrates support for tobacco control initiatives. Over the past two years, the program has focused heavily on a new statewide action project to raise awareness of the tobacco prevalence in Hollywood productions. Over 5,000 letters were written by county youth to the Motion Picture Association, State Legislators, and the Director s Guild requesting a stop to positive portrayal of smoking in motion pictures. Tobacco Free Schools Schools are the target audience for this policy development program. The Tobacco Free Schools Public Health Educator (PHE) works primarily with school Health and Wellness Committees to either update schools existing policies or establish a new comprehensive tobacco policy. This is also sometimes accomplished at the district level. Support and direction are provided to the school communities on policy implementation and evaluation as well. Staff surveys and observational studies are tools utilized by the PHE to determine school needs. Alternative to suspension programs are offered for enforcement of newly adopted policies. Lyme Disease Prevention Education and Surveillance The Lyme Disease Education Program from NYSDOH funds.25 FTE of a Community Health Worker supplemented by assistance from a county-funded Senior Public Health Educator during the spring and summer seasons. The Senior Public Health Educator provides the majority of information services to the public and presentations to community-based institutions and schools. Other CHO staff members contribute to the education program at health fairs and community events. Lyme disease prevention and early detection information is provided to residents including OCDOH s biannual publication, Summer Health Connection. Migrant Health Services Program Over the years, the number of true Migrant Seasonal Farm Workers (MSFW), people who move with the crops, has dwindled in Orange County as in the region. The difficulty now associated with leaving the country and coming back has resulted in many workers remaining year round in Orange County s cities. The availability of lower paying year round jobs or day work has also led many migrants to become more sedentary. In 2007, CHO reached approximately 400 true MSFWs who received culturally and linguistically appropriate prevention education and materials to help keep them safe on the job. This is approximately 16% of the MSFW population the program served in the last decade. The strict definition for eligibility of persons to be served by this program curtails our services to the larger migrant population. With increased bilingual staff, OCDOH plans to engage many new permanent residents. Environmental Health Division The workload for the Division of Environmental Health is driven by external forces, the demands of the State and Federal overseeing bodies (e.g. plan review). The three major programs used 67% of the Division s technical staff during the year 2008; food service 20%, water 37%, and realty subdivisions 10%. Water continues to be the largest program because of the funds infused by the State into an enhancement program that funds and supports 3 FTE engineers. The trend for the water program is for the E.P.A. to continue to impose new requirements on the water purveyors. Regulating and enforcing these requirements is passed on to the local health department. Orange County Community Health Assessment 2010-2013 Section II 16

The workload to review engineering plans is obviously dependent upon what is submitted. Orange County is the fastest growing county in the State creating the attempt to build homes and catch the market. This approach has people trying to develop marginal lands as much of the better property has been developed. Submittals of sewage disposal systems in poor soils require a longer and more detailed review by staff engineers. If the trend of increased numbers of plans and designs in poor soils continues, OCDOH will be looking for additional staffing to maintain our service goal. The significant population growth has had two effects on the food service program. There has been the construction of national and regional chain restaurant outlets coupled with the opening of ethnic facilities. In the past, many of the proposals were for pizzerias, Asian restaurants and bagel shops. More recently, many applications originate from Hispanic/Latino restaurants to accommodate our urban Hispanic population. The sanitarians and technicians have had to learn the specialized nature of each type of cooking and how practices can be modified to conform to the health requirements of the Sanitary Code. Many restaurant closings have kept the workload in this area relatively constant. Orange County Community Health Assessment 2010-2013 Section II 17

SECTION TWO: LOCAL HEALTH UNIT CAPACITY PROFILE C. NEW INITIATIVES AND SIGNIFICANT ACCOMPLISHMENTS Administration Continuity in the Department s leadership has supported development and implementation of new program initiatives and ongoing program improvement. p Jean Hudson, M.D., M.P.H. has been the County Commissioner of Health since September 2003. p Chris Dunleavy, an experienced county administrator, has been Deputy Commissioner since March 2004. The Office for Public Health Emergency Response, funded through BT/PHEPR, reports directly to the Commissioner of Health. Total federal and state grant funding awarded to support program initiatives for FY 2008 exceeded $2 M. The Office of the Medical Examiner was established and began operation on January 1, 2008. Orange County s first Medical Examiner is Dr. Charles Catanese, an experienced forensic pathologist. Public Health Nursing Division TB Program - In 2004, the OCDOH TB program saw a significant increase in the foreign-born cases in Middletown and Newburgh, 67% of the patients being treated were foreign-born. In 2005, the TB program managed an MDR case. In August 2005, the TB program PHN was trained and certified to be an HIV counselor; HIV counseling and testing is now offered at all TB clinics. In 2006, the TB program had the highest count of TB suspects (17) during 2004-2008 which were all determined not to be TB. In March 2006, a TB case involving two major food chains was investigated and treated. In 2007, TB testing was initiated at the Orange County Jail which is now an annual physical exam requirement. Immunization Program - The nationwide shortage of haemophilus influenza type B (HIB) vaccine became a critical issue in the county in 2008 and this unfortunate trend is continuing in 2009. There has been an increase in reported cases of this vaccine preventable childhood disease in the county, state, and nation. As local physician s vaccine inventory was depleted, OCDOH immunization program was able to supply physicians with vaccine. Thus, the program became a very valuable resource for Orange County residents. WIC - The 2009 caseload is currently 7,469 and the program achieved 100 percent of our approved caseload. An additional Farmer s Market was added in Newburgh in close proximity to the WIC Program this past year, which was highly successful. The new food package was introduced in January 2009 promoting age-appropriate use of skim/1% milk, whole wheat bread, brown rice, tofu and increased dollar value of checks for fresh fruits and vegetables in grocery stores. CHHA/LTHHCP - In 2006 a new integrated patient care computer system with point of care documentation was implemented. The 3-M system supports clinical documentation by edits and alerts throughout the real time OASIS error checking, medication teaching and interaction sheets and automated ICD coding. It supports the Nursing process by accessing, planning, implementation and evaluation. The point of care system has provided clinicians with the ability to complete patient documentation in a concise and timely manner. Disease Control The focus for disease control is active surveillance for communicable disease activities. Electronic laboratory reporting allows for immediate investigation and intervention to further reduce the level of communicable disease and prevent outbreaks. The Nursing Division received training in Field EPI 101: Outbreak Investigation. The objectives of this training were: to be able to identify the steps and processes in an outbreak investigation, to understand the role of the county, state and federal health agencies in working collaboratively during such an event, and to implement control measures to prevent further transmission of disease. Disease Control worked closely with NYSDOH on outbreaks of shigella and salmonella over the last year. From 2004-2008 the agency is still seeing an increase in Pertussis and the department works closely with providers, parents, and schools to avoid outbreaks on a continuing basis. The Partner Notification Program investigated 230 cases of HIV infection with between one and three contacts per case notified and brought into medical evaluation. Intervention Services Division Implemented a new scheduling system with Early Intervention (EI) providers to achieve a more efficient and cost effective system. Added an Early Intervention Supervisor to the staff to provide direct supervision for the increasing Initial service Coordination staff and to develop and implement quality monitoring measures. Developed both Early Intervention and Preschool Special Education Procedure Manuals and distributed them to all providers, Ongoing Service Coordinators, and school district CPSE Chairpersons. Revised the EI Individual Family Service Plan to address more clearly the parent s rights and responsibilities in EI for children with autism. Orange County Community Health Assessment 2010-2013 Section II 18

Worked with the NYSED Regional Associate to review Special Education Itinerant Teacher (SEIT) and the SEIT programs. Community Health Outreach Division Public Health Education - In 2008, Community Health Outreach attended 28 community events reaching over 2,700 people with prevention education. Healthy Orange p Over the past two years, Healthy Orange has implemented worksite wellness programs in 36 worksites and has increased access to free heart screenings to 1,251 employees. p Since 2006, Healthy Orange provided obesity prevention education and intervention to 18 schools including students, staff and families. p In June 2008, Healthy Orange piloted a new obesity prevention program for childcare centers. Healthy Orange will work with three new sites each year to assist them with policy and environmental change to ensure improved nutrition and increased physical activity. p Eat Well Play Hard From July - November 2008, a new Farmer s Market was established by the Health and Wellness Coordinator in the city of Newburgh with the goal of increasing availability of regionally grown produce for low income residents. The Farmer s Market reached approximately 200 shoppers weekly. In September 2008, A Sports, Play and Active Recreation for Kids (SPARK) training was provided to 28 personnel from the Newburgh and Middletown school districts, the YMCA, and other childcare agencies. Since the training, this curriculum is being used at a number of afterschool programs in Middletown and Newburgh, as well as being added to the physical education curriculum at two Newburgh schools. Lead Safe Orange Through Lead Safe Orange, we successfully expanded the outreach efforts of the Healthy Neighborhoods, Primary Prevention, and LBPHC programs. During 2008, there were a total of 517 home visits. Through these programs, 689 outreach and education events were conducted, reaching over 6,000 individuals in a variety of venues. p Childhood Lead Poisoning Prevention Program In 2008, CLPPP staff opened 28 new cases for children who had a BLL of >20 ug/dl. CLPPP staff continued to case manage 113 lead poisoned children and their families and monitor lead testing compliance and results for approximately 75 new children with a BLL between 10 and 19 ug/dl. p Healthy Neighborhoods Program There were a total of 418 visits, which include initial and revisits for 2008. Out of this number, 350 households had children 6 years of age and under and 285 of those children had been tested for lead. HNP had 254 residents take the Smoke Free Home Pledge during 2008. p HUD Lead-Based Paint Hazard Control Program Throughout 2008, LBPHC had 613 outreach and education events, contacting approximately 1,692 people. Subsequently, 31 housing units were cleared and completed as lead safe by the Office of Community Development through their grant and loan programs. p Primary Prevention Program Since July 2008, PPP has completed 130 home visits and 100 lead paint hazard investigations which have triggered 61 letters of Notice and Demand. Community Health Worker Program In March of 2007, the OCDOH was awarded a grant from the March of Dimes to provide prenatal education classes targeted primarily to Hispanic/Latina women in the county. In 2008, nearly 100 women were served, and all babies born to mother's who participated in CHWP were born at a healthy birth weight. Tobacco Control Program TCP began a new initiative to create Smoke Free Playgrounds throughout the county called Young Lungs at Play. In 2009, the program secured the support of the Orange County Parks Commissioner. The Smoke Free Homes and Cars Campaign garnered over 3,300 residents/families in the county who agreed to have pledged to have smoke free homes and cars. Tobacco Cessation The OCDOH referred 177 individuals to contracted cessation providers during 2008. Tobacco Free Schools Program As of 2009, the TFS program is actively working with 21 schools from eight districts. Fourteen schools in six county districts have adopted improved policies with support and guidance from our TFS staff. Seven schools have signed Memorandums of Understanding and are working toward adoption of formal policy. Lyme Disease Prevention Education Program In 2008, the Lyme Disease Prevention Education Program reached 11 school districts with 82 programs attended by over 1,900 students, faculty, staff and residents. The program has also reached outdoor at-risk worker programs (600 kits distributed) and provided community presentations to 375 residents. The program also reached 1,000 camp counselors at 19 sleep-over camps and distributed information in every library, municipality and DMV in the county. Migrant Health Services Program In 2008, a coalition of Migrant service providers was established, allowing the group to work together and better understand many of the services offered to the migrant workers and their families. Orange County Community Health Assessment 2010-2013 Section II 19

Environmental Health Division The Division of Environmental Health worked closely with the Public Water Supplies and the NYSDOH to obtain higher eligibility for Drinking Water State Revolving Fund (DWSRF) funding in Orange County. Presently, there are 89 Orange County projects on the Multi-year list for funding with a total value of $130 million. Of these, eight projects with a total value of $19 million are on the Readiness list for funding. OCDOH continues to improve the accuracy of our public water sources and treatment plant locations on the GIS system. In response to amendments to Public Health Law, OCDOH guided and assisted 21 Community Water Supplies through the vulnerability assessment process and subsequent upgrades to their Emergency Response Plans. In 2008, 481 petroleum and other hazardous materials spills were investigated. Office of Public Health Emergency Response Drills and Exercises - The Office of Public Health Emergency Response (OPHER) participated in numerous exercises designed to better prepare Orange County to respond to a natural disaster, disease outbreak, or act of terrorism. Some of these include; a mass causality drill with the US Military Academy which included the use of the OCDOH MRC, a Strategic National Stockpile drill in Syracuse NY, a joint Biological Detection System (BDS) training session with the United States Postal Inspection Service, numerous communications drills, and a flu vaccination POD for county Emergency Service Workers that used MRC members who worked jointly with OCDOH staff in administering vaccine. Psychological First Aid Training for Employees- The OPHER has continued to establish training for employees to take Psychological First Aid certification at the direction of the NYSDOH. Approximately 20% of the staff currently has the certification with additional staff expected to complete the course this year. This training gives the Department additional resources for employees to help in large scale disasters. Epidemiological Surveillance - The OPHER has enhanced the capacity of OCDOH s disease surveillance system to detect the possible outbreak of an emerging disease or a bioterrorism agent. Data for this enhanced surveillance system is gathered from school absentee data, over the counter medication purchases, 911 calls, emergency room chief complaint reports, and laboratory reports. Regional Preparedness - On a monthly basis, the Hudson Valley Bioterrorism Coordinators (HVBC) meet to discuss preparedness activities which include NYSDOH and CDC deliverables for the current year. In addition, coordinators attend Regional Preparedness Council (RPC) meetings on a quarterly basis with all hospitals in the Hudson Valley Region. At these meetings coordination activities result in better regional planning that cross public and private sector boundaries resulting in more effective and efficient responses. Orange County Community Health Assessment 2010-2013 Section II 20

SECTION TWO: LOCAL HEALTH UNIT CAPACITY PROFILE D. STAFF QUALIFICATIONS AND SKILL LEVELS The Orange County Department of Health is charged with protecting and promoting the health of county residents, and employs qualified and specialized staff to perform these vital services. As of July 1, 2009, there were 179 budgeted positions (including county and grant funded positions) in the Department. A complete listing of staff titles and program assignments by Division are provided in Exhibit 2.5 at the end of this section. A diversity of skilled health professionals and paraprofessionals are required to accomplish our mission, including: physicians; nurses; nutritionists; health educators; engineers; sanitarians; epidemiologists; social workers; speech, occupational and physical therapists; health and financial investigators; service coordinators; community health workers; community outreach workers; HIV counselors; accountants; as well as administrative and support staff. New York State licensure/certification is a requirement for many positions, and the Department actively recruits bilingual staff in all program areas serving the public. The delivery of public health programs and services is collaborative by nature, and the Department works closely with a multitude of state, regional, county, and federal agencies and organizations. OCDOH staff collaborate extensively with NYS agencies, first and foremost with the New York State Department of Health and New York State Department of Environmental Conservation. Division staff communicate often with their program counterparts at the State level as well as with other county agencies on projects of mutual interest. Staff collaborate with community groups and agencies, schools, child care centers, businesses, and with local and regional health, mental health, and social service providers and organizations. Staff actively participate in regional and local task forces and coalitions that are aligned with program goals and objectives, often serving in a leadership capacity. A detailed listing of staff collaborations and affiliations is provided in Section III (A) Profile of Community Resources. In our Public Health Nursing (PHN) and Intervention Service programs, service coordination and continuity demands that strong partnerships are established with a host of agencies. As an example, PHN staff collaborate daily with infection control personnel at local hospitals, and interface with other home care agencies in the county for reciprocal referrals. The Early Intervention staff participate in the Local Intervention Coordinating Council to assure seamless services are provided to clients and to advocate for needed services. The Department provides guidance to other county agencies involved with public health issues, including the Departments of Social Services, Mental Health, Emergency Management, Law, Environmental Facilities, Consumer Affairs, Public Works, Parks and Recreation, the Youth Bureau, county-based Correctional Centers (state and federal), as well as the County Executive and the Legislature. The Department serves as a clearinghouse for public health information which is disseminated to the public, providing health statistics and analyses to the public and community agencies, and advice and technical guidance to health providers in the community. The Department s Public Health Educators interact with representatives from community and voluntary agencies as well as the public through phone calls, health fairs, and presentations to community groups and schools. Press releases are issued on important health topics and information on emerging issues is blast faxed/emailed to county physicians. The educators develop the content for a widely disseminated area newspaper insert published twice per year, to update the public and community agencies on timely public health issues. They also develop the content of the monthly health awareness campaign on the county website. Staff qualification highlights by Division follow: Public Health Nursing Division This is the largest Division within the Department, with a total of 69 FTEs. The Director and 3 of the 5 FTE supervising public health nurses have advanced degrees in public health and health service management. All 15 FTE public health nurses have B.S. degrees in nursing. All six Registered Professional Nurses have A.S. degrees in nursing and three are pursuing baccalaureate degrees. All nursing staff are licensed registered nurses in New York State. The WIC program employs six nutritionists and one Public Health Nurse who are licensed by New York State. The two Public Health Investigators are baccalaureate prepared and one is fluent in Spanish. In addition, the Division contracts with outside agencies for the CHHA/LTHHCP services: physical and occupational therapy, speech and language pathology, medical social work, respiratory therapy and home health and personal care aides. Support staff within the Division include a senior secretary/administrative assistant, secretaries, typists, bilingual receptionists, outreach worker and an account clerk. Intervention Services Division The Intervention Services Division consists of 24.5 FTE positions, with extensive expertise in early childhood development, special education services, and maternal, infant, and child health. The Director has a masters degree in nursing with a concentration in maternal and child health and a masters degree in education. The Program Coordinator is a Supervising Public Health Nurse, and has an MPH. The EI Supervisor has a masters in Special Education. The program contracts with approximately 70 individual therapists and 75 Orange County Community Health Assessment 2010-2013 Section II 21

agencies to provide services for EI and Preschool. All services with the exception of Initial Service Coordination are provided by contractual personnel. In addition, the program contracts for 1) provider scheduling via e-mail, 2) oversight of Preschool and EI transportation services, and 3) transportation services for EI and Preschool children. Community Health Outreach Division The Division consists of 29 FTE positions. The Director, Assistant Director, Health & Wellness Coordinators, Public Health Educators and Coordinators have appropriate education, degrees and training for their positions. The Director has nineteen years experience in the administration of programs for Community Health Outreach. All community health workers have community-based experience. Regarding bilingual (English/Spanish) positions, 2 of the 7 Public Health Educator FTEs are designated bilingual and 4 of the 12 Community Health Worker FTEs are designated bilingual. Environmental Health Division The Division of Environmental Health is the second largest Division within the Health Department, with a total of 30 full-time engineering, sanitarian, technician and support staff positions. The Director, the Principal Public Health Engineer, and three Senior Public Health Engineers are all licensed engineers. All technical staff meet the education, experience and training requirements set forth in the NYS Sanitary Code. The staff consists of the Director, nine engineers, seven sanitarians, seven technicians, and six clerical positions. The Division is particularly proud of its history of retaining staff and promoting from within which has resulted in a well-trained and experienced staff. Office of Public Health Emergency Response The Director of the OPHER has a Masters Degree in Public Administration and has been certified by the Federal Emergency Management Administration, the State Emergency Management Office, and the New York State Department of Health in many aspects of emergency management. The Director has 2 years of experience in this particular position and has been employed with the Department of Health for 14 years. Orange County Community Health Assessment 2010-2013 Section II 22

SECTION TWO: LOCAL HEALTH UNIT CAPACITY PROFILE E. EXPERTISE AND TECHNICAL CAPACITY FOR COMMUNITY HEALTH ASSESSMENTS Historically, staff throughout the Department have participated in assessing community health needs and the adequacy of services. This is inherent in their program responsibilities and involves all levels of program staff. The Department s field staff and outreach workers lend much insight into unmet health needs and service gaps from their daily interactions with high risk individuals and grassroots community leaders. Newly arrived immigrants are often more likely to share their concerns with public health staff who are indigenous to the community. Bilingual and bicultural staff greatly assist the Department in providing services to residents who would otherwise be difficult to reach. The Department actively recruits multicultural staff as vacancies permit. The Department incorporated guidance from APEXPH (Assessment Protocol for Excellence in Public Health) in planning for the 2010-2013 Community Health Assessment. A public health consultant served as the project director, working with an internal CHA Development Team with representatives from all Divisions and the Orange County Department of Planning. The Department currently has a part-time nurse epidemiologist and an epidemiology fellow. A contract with the SUNY Albany Prevention Research Center was used to compile and analyze relevant sociodemographic and health status indicators. In addition, a CHA Prevention Agenda Workgroup was convened by the Commissioner of Health to provide input and guide the development of the identification of unmet health and service needs, local health priorities aligned with the NYS 2008 Prevention Agenda, and opportunities for action. Prevention Agenda Workgroup representatives have a broad base of knowledge and experience public health/health advocacy, health services delivery, and culturally and language appropriate service to high risk populations throughout the county. (See Section IV Exhibit 4.3) As previously discussed in Section IB: Access to Care, two surveys were developed to better assess health care access and local health needs one targeting community agencies and major health care providers and the second targeting residents/health consumers. These surveys were developed in partnership with HVRHON and researchers at New York Medical College School of Public Health (NYMC-SPH) as a component of a region-wide assessment of local health needs funded through the NYS HEAL 9 grant. Agencies and health care providers included in the survey were determined by the Prevention Agenda Workgroup and are listed in Section IV: Local Health Priorities. The community agency and health provider surveys were distributed to participants in the Health Town Meetings co-led by the Commissioner of Health and area hospital/medical center and Community Health Center leads. These meetings were convened at hospital locations and were attended by health, behavioral health, social service, education, community and faith-based agencies and consumer advocates in geographically distinct areas of the county. (See Section IV Exhibits 4.2a-e) The meetings included a presentation of the purpose and methods involved in conducting a Community Health Assessment, followed by a discussion of health data and survey findings and the NYS Prevention Agenda. This resulted in further refinement of local health priorities within the county. A resident/health consumer survey focused on health behaviors and needs related to the three priority areas identified for the lower Hudson Valley Region - Access to Quality Health Care, Healthy Mothers/Healthy Babies/Healthy Children, and Chronic Disease. Public Health interns administered questionnaires in diverse locations throughout the county; over 760 surveys were completed. Survey findings are presented in Section IV. Orange County Community Health Assessment 2010-2013 Section II 23

Exhibit 2.1A Orange County Department of Health Departmental Administration Jean M. Hudson, M.D., M.P.H Commissioner Christopher J. Dunleavy Deputy Commissioner Office of the Medical Examiner Environmental Health Division Intervention Services Division Community Health Outreach Division Charles A. Catanese, M.D. Chief Medical Examiner Matthias J. Schleifer, P.E. Assistant Commissioner Environmental Health Sheila Warren, R.N., M.Ed. Director Intervention Services Robert J. Deitrich Director Community Health Outreach Administrative Support Fiscal Division Public Health Nursing Division Emergency Preparedness Unit Christine Saccone Executive Secretary/Administrative Asst Anne Vradenburgh Fiscal Manager Marilyn Ejercito R.N., M.S. Director Patient Services Christopher Ericson, M.P.A. Director Public Health Emergency Response Jennifer Corliss Senior Secretary/Administrative Asst Angela Colon Senior Clerk Support (Contractual) Gerie Dunn MRC Coordinator Robert Hastings Health Tech Specialist Colleen Larsen, R.N., M.P.A. Epidemiologist Orange County Community Health Assessment 2010-2013 Section II 24

Exhibit 2.1B Orange County Department of Health Environmental Health Division Matthias J. Schleifer, P.E. Assistant Commissioner Environmental Health Bureau of Sanitary Engineering Edwin L. Sims, P.E., Director Principal Public Health Engineer Administrative Support Unit Donna Bailey Secretary/Administrative Assistant Bureau of Sanitary Control John D. Score, Director Principal Public Health Sanitarian Lee Bergus, P.E. Keith Miller, P.E. Greg Moore, P.E. Senior Public Health Engineers Aurilla Card Sandra Ovens Cheryl Karlin Rhea Weber Catherine Martorano Administrative Support Staff Jane Harkinson Senior Public Health Sanitarian Michael Anderson Steve Gagnon Edward Behnke James Sturomski Frank Demuth Public Health Engineers Thomas Laruccia Donald Lipton Public Health Technicians Jay Babula Deborah Memmelaar Stephen Collins John Pohja Tim Gaeta Public Health Sanitarians Sharon Decker Bob Hodge Michael Gauthier Alan Kalleberg Scott Greene Public Health Technicians Orange County Community Health Assessment 2010-2013 Section II 25

Exhibit 2.1C Orange County Department of Health Fiscal Division Anne Vradenburgh Fiscal Manager Intervention Services Unit Accounts Receivable Unit Fiscal Support Unit Payroll Unit Lisa DeNisco Associate Account Clerk I Marie Merlo Principal Account Clerk Camille Cornine Accounting Supervisor Mary Alice Conway Principal Account Clerk Barbara O Keefe Principal Account Clerk Darcy Hilleary Senior Account Clerk Linda Gove Senior Account Clerk Donna Black Account Clerk Accounts Payable Unit Carleen Schaumburg Principal Account Clerk Medical Examiner Support Deborah Slesinski Principal Account Clerk Gretchen Riordan Ginger Leitner Account Clerks Patricia Reed Clerk II Diane Milletti Senior Account Clerk Vacant Account Clerk Brooke Wierzbicki Vacant Clerk II Orange County Community Health Assessment 2010-2013 Section II 26

Exhibit 2.1D Orange County Department of Health Intervention Services Division Sheila Warren, R.N., M.Ed. Director Intervention Services Administrative Support Unit Pre-K Special Education Program Maternal/Child Health Unit Early Intervention Services Maryann Melville Senior Secretary/Admin Asst Susan Lee Lydia Paulson Special Education Coordinators Ann Craig Supervising Public Health Nurse Carol Abenanti Early Intervention Supervisor Lynn Nivins Associate Clerk Peggy Carter Financial Investigator Lillian Diaz Secretary Vacant Typist 1 Betty Ferguson Typist 1 Marlene DeMarco Senior Clerk Sue Chernek Barbara Lewis Public Health Nurses Denise Barbiantz Kathy Esposito Jennifer Frey Kathy Grupp Meghan hawk Bridget Kolka Jessica Lopez Pamela Lorenzo Lori Muniz Vanessa Rivera Dena Sapp Debra Scuadroni Meghan Stevens Vacant Early Intervention Services Coordinators Orange County Community Health Assessment 2010-2013 Section II 27

Exhibit 2.1E Orange County Department of Health Public Health Nursing Division Goshen Office Marilyn Ejercito, R.N., B.S.N, M.S. Director Patient Services Immunization Action Program Goshen Office Physical Therapy Program Administrative Support Stephen Goodell Supervising Public Health Nurse Ellen Parrinelli Supervising Public Health Nurse Vacant Supervising Physical Therapist Brenda Cosner Senior Secretary/Administrative Asst Barbara Valure Public Health Nurse Helen Loendorf Debora Fagan Vacant Public Health Nurses Roxanne Babcock Tiffany Graham Kathy Hanley Secretaries Susan Crean Margaret Tirpak Nancy Stavrides Christine Belknap Registered Nurses Laurie Yungman Marian Sabins Lisa Eckert Home Health Aides Orange County Community Health Assessment 2010-2013 Section II 28

Exhibit 2.1F Orange County Department of Health Public Health Nursing Division Newburgh, Middletown and Port Jervis Offices Marilyn Ejercito, R.N., B.S.N., M.S. Director Patient Services Middletown Office Diane Higgins Supervising Public Health Nurse Port Jervis Office Nancy DeLauro Anne Sigmund Public Health Nurses Administrative Support Kristina Rourke Secretary Tina Mariano Spanish Speaking Receptionist Newburgh Office Patrice Fogarty Mary B. Marsh (Long Term Care) Vacant Supervising Public Health Nurses Norah Meyer Judith Oppelt Home Health Aides JoAnn Weed Wuanda Gonzalez Account Clerk Spanish Speaking Receptionist Wanda Cruz Tania Rayford Christine Zwart Community Health Typist Typist Outreach Worker Madeline Nolan Vacant Simi Raman Vacant Donnetta Seabrook-Burley Nakresha Joseph Public Health Nurses TB Program Maria Esling Public Health Nurse STD Program Carlos Montalvo Dan Parlman Public Health Investigators Cheryl Ferrante Eileen Reilly Pamela Weissflog Public Health Nurses Maricruz Edwards Registered Nurse Yvonne Comeau Vacant Moreen VanCouten Vacant Vacant Vacant Registered Nurses Administrative Support Cecelia Jordan Anjelica Rodriguez Michele Travis Patricia Kulzer Secretary Spanish Speaking Receptionist Typist Typist Dorothy Hunt Margaret Sebasta Geraldine Melvin Patricia Drago Nili Raphael Home Health Aides Orange County Community Health Assessment 2010-2013 Section II 29

Exhibit 2.1G Orange County Department of Health Public Health Nursing Division Women, Infants and Children (WIC) Program Marilyn Ejercito, R.N., B.S.N, M.S. Director Patient Services Mary Jackson Nutritionist/Coordinator Newburgh Office Jill Hansen Supervising Nutritionist Middletown Office Kathy Blessing Public Health Nurse Harriman Office Marian Holdridge Supervising Nutritionist Patricia Still Nutritionist Laura Hubbell Nutritionist Elizabeth Apel Angela Koenig Nutritionists Administrative Support Susan Baltrow Principal Nutrition Assistant Agnes Gelsomino Senior Nutrition Assistant Administrative Support Judy Lopez Sr. Nutrition Assistant English/Spanish Alice Ruiz Nutrition Assistant English/Spanish Administrative Support Miriam Hanlon Senior Nutrition Assistant Theresa Nicki Nutrition Assistant Orange County Community Health Assessment 2010-2013 Section II 30

Exhibit 2.1H Orange County Department of Health Community Health Outreach Division Robert J. Deitrich Director, Community Health Outreach Maureen Useo Assistant Director Tobacco Education Unit M. Wickes Sr. PHE Migrant Health Services W. Cruz Sr. CHW K. Barnett B. Hoeffner L. Spitzner PH Educators B. Lewis PHN Community Health Worker Program K. Smith Coordinator K. Caruso C. Formisano O. Hernandez V. Villegas CHWP CHWs Lead Safe Orange H. Meehan M. Braverman E. Martinez-Salazar PH Educators L. Jansen M. Torres G. Clegg M. Decker M. Salazar E. Pinos-Granda CHWs S. Chernek PHN Healthy Orange D. Moser Sr. PHE M. Oakes Vacancy Health/ Wellness Coord. Administrative Unit C. Pearl ATUPA Coord. J. Mulvey ATUPA CHW S. Fonseca Admin. Asst. A. Rubin Secretary Orange County Community Health Assessment 2010-2013 Section II 31

Exhibit 2.1 I Orange County Department of Health Medical Examiner s Office Charles A. Catanese, M.D. Chief Medical Examiner Barbara K. Bollinger, M.D. Deputy Chief Medical Examiner Administrative Support Marie Borth Executive Secretary/Administrative Asst Kathy Hussey Secretary Contractual Support Medical Examiners Joseph P. Tully Chief Medical Investigator Contractual Support Medical Investigators Autopsy Assistants Orange County Community Health Assessment 2010-2013 Section II 32

Exhibit 2.2 ORANGE COUNTY DEPARTMENT OF HEALTH PROGRAM CONTACT NUMBERS Administration/Commissioner s Office (845) 291-2332 Public Health Nursing (845) 291-2330 HIV/STD Screening (845) 568-5333 Immunization Clinics (845) 291-2369 Tuberculosis Clinics (845) 346-1113 WIC (845) 291-2044 Environmental Health (845) 291-2331 Early Intervention Services (845) 291-2333 ICHAP/Child Find (845) 568-5280 Physically Handicapped Children's Program (845) 291-2569 Community Health Outreach (845) 568-5237 Childhood Lead Poisoning Prevention (845) 568-5253 Comprehensive Tobacco Program (845) 568-5238 Reality Check (845) 568-5246 Lyme Prevention/Education (845) 291-2336 Public Health Emergency Response (845) 291-4836 Orange County Community Health Assessment 2010-2013 Section II 33

Exhibit 2.3 ORANGE COUNTY DEPARTMENT OF HEALTH INTERVENTION DIVISION PROGRAM SPECIFICS SERVICE SITE HOURS CLIENTS Early Intervention Home/community/ clinics/group settings Typically 9-5 Sunday through Saturday, also 5-8. Children birth to 3 who have a developmental delay or a condition that results in a developmental delay Child Find/ICHAP Home/community Monday through Friday 9-5. Visits and activities on area also scheduled on weekends Children birth to 3 who are at risk for a disability Preschool Special Education Program Home/community/ Schools Monday through Friday 8-4. Follows school calendar. Limited services in July/August for limited number of children 3 & 4 year old children Physically Handicapped Children s Program Clinics/ MD offices Per provider office hours Birth to 21 Children with Special Health Care Needs Perinatal Hepatitis B Program Newborn Hearing Screening Program Newborn Screening Home/community/ medical facilities, etc. Hospitals, MD offices/home Hospitals, clinics Hospitals, clinics, home 9-5 Monday through Friday Birth to 21 9-5 Monday through Friday HbsAG positive mothers and their infants 9-5 Monday through Friday Infants 9-5 Monday through Friday Infants Adult Polio Home 24/7 Adults with polio SIDS Home/community 9-5 Monday through Friday Families of children who die of SIDS Orange County Community Health Assessment 2010-2013 Section II 34

Exhibit 2.4 I M M U N I Z A T I O N ORANGE COUNTY DEPARTMENT OF HEALTH DIVISION OF PUBLIC HEALTH NURSING CLINIC SCHEDULES 2009 SERVICE SITE DAYS/HOURS CLIENTS C L I N I C S ADULT TRAVEL CLINICS H.I.V. TESTING/ S.T.D. CLINICS TB CONTROL CLINICS W.I.C. PROGRAM OCHD - 291-2330 124 Main St. Goshen, NY OCHD - 346-1113 33 Fulton Plaza., Middletown, NY OCHD - 568-5333 141 Broadway, Newburgh, NY OCHD - 858-1468 168 East Main St., Port Jervis, NY OCHD - 291-2369 124 Main Street Goshen, NY OCHD - 346-1113 33 Fulton Plaza, Middletown, NY OCHD - 568-5333 141 Broadway, Newburgh, NY 346-1113 - OCHD, Middletown, NY 568-5333 - OCHD, Newburgh, NY Monroe - 291-2044 Middletown - 346-1300 Newburgh - 568-5288 3 rd Tuesday every month/9:30-11:30 a.m. By Appointment only. 2 nd and 4 th Tuesday every month/9:30-11:30 a.m. By Appointment only. 1 st and 3 rd Tuesday every month/9:30-11:30 a.m. 4 th Wednesday of every month/3:00-5:00 p.m. By Appointment only. 1 st Wednesday every other month/9:30-11:30 a.m. Feb, Apr, Jun, Aug, Oct, Dec By Appointment only. 2 nd Wednesday every month/9:30 a.m. - 4:00 p.m. By appointment only. Friday - Walk-in/ 1:00 3:00 p.m. Walk-ins are seen. Thursday evenings /6:00-8:00 p.m. Walk-ins are seen. Call for clinic schedules. Information/Intake/Clinic Sites are available by assignment. Children 18 and under. Parent or legal guardian must accompany child and bring a copy of immunization record. College bound students can receive MMR regardless of age. Foreign travel and college bound students. Public Public Women Infants Children Orange County Community Health Assessment 2010-2013 Section II 35

Exhibit 2.5 Environmental Health Orange County Department of Health FTEs by Division Management Director of Environmental Health Services 1.0 Professionals Principal Public Health Engineer 1.0 Principal Public Health Sanitarian 1.0 Senior Public Health Engineer 3.0 Senior Public Health Sanitarian 1.0 Public Health Engineer 5.0 Public Health Sanitarian 5.0 Technicians Public Health Technician 7.0 Administrative Support Clerk II 1.0 Principal Clerk 1.0 Secretary/Administrative Assistant I 1.0 Senior Clerk 1.0 Secretary 1.0 Typist I 1.0 Total 30.0 Public Health Administration Management Commissioner of Health 1.0 Deputy Commissioner of Health 1.0 Director of Public Health Emergency Response 1.0 Medical Examiner 1.0 Professionals Fiscal Manager 1.0 Accounting Supervisor 1.0 Chief Medical Investigator 1.0 Administrative Support Account Clerk 3.0 Clerk II 2.0 Executive Secretary/Administrative Assistant 2.0 Principal Account Clerk 5.0 Senior Secretary/Administrative Assistant 1.0 Senior Account Clerk 3.0 Associate Account Clerk I 1.0 Intern 0 Senior Clerk 1.0 Secretary 1.0 Total 26.0 Orange County Community Health Assessment 2010-2013 Section II 36

Intervention Administration Management Director of Early Intervention Services 1.0 Professionals Special Education Program Coordinator 2.0 ICHAP Coordinator 1.0 ICHAP Nurse 1.0 Early Intervention Service Supervisor 1.0 Para/Professionals Financial Investigator/PHC 1.0 Early Intervention Service Coordinator 13.0 Administrative Support Senior Secretary/Administrative Assistant 1.0 Associate Clerk 1.0 Typist I 1.0 Secretary 1.0 Senior Clerk 0.5 Total 24.5 Public Health Nursing Management Director of Patient Services 1.0 Professionals Public Health Nurse 15.0 Registered Professional Nurse 6.0 Supervising Public Health Nurse 5.0 Supervising Public Health Physical Therapist 0 Public Health Investigator (STD) 2.0 Nutrition Program Coordinator 1.0 Supervising Nutritionist 2.0 Nutritionist 4.0 Para/Professionals Home Health Aide 12.0 Community Health Outreach Worker 0 Administrative Support Account Clerk 1.0 Receptionist (Spanish/English) 3.0 Senior Secretary/Administrative Assistant 1.0 Secretary 5.0 Typist I 4.0 Principal Nutrition Assistant 1.0 Senior Nutrition Assistant 2.0 Senior Nutrition Assistant (Spanish/English) 1.0 Nutrition Assistant 1.0 Nutrition Assistant (Spanish/English) 2.0 Total 69.0 Orange County Community Health Assessment 2010-2013 Section II 37

Community Health Outreach Professionals Director Community Health Outreach 1.0 Senior Public Health Educator 2.0 Public Health Educator 4.0 Community Outreach Coordinator 2.0 Assistant Director of Community Health Outreach 1.0 Health & Wellness Program Coordinator 2.0 Public Health Nurse 1.0 Public Health Educator (Spanish/English) 2.0 Para/Professionals Senior Community Health Outreach Worker (Spanish/English) 1.0 Community Health Outreach Worker 8.0 Community Health Outreach Worker (Spanish/English) 3.0 Administrative Support Secretary/Administrative Assistant II 1.0 Secretary 1.0 Total 29.0 Orange County Community Health Assessment 2010-2013 Section II 38

ORANGE COUNTY COMMUNITY HEALTH ASSESSMENT 2010-2013 SECTION THREE: PROBLEMS AND ISSUES IN THE COMMUNITY A. PROFILE OF COMMUNITY RESOURCES B. PROFILE OF UNMET NEEDS FOR HEALTH SERVICES Community Resources A wide range of community-based health resources are available to Orange County residents. OCDOH provides information on request regarding available healthrelated programs and services to residents, health care providers, and community agencies. In addition, the Department s public health nurses, educators, outreach workers, health investigators, and other field staff provide ongoing guidance on health-related resources through community events and outreach activities. The Orange County Department of Health Resource Guide for Health-Related Services (Exhibit 3.1), located at the end of this Section describes the principal resources available countywide; additional municipal resources are cited throughout this report. The Orange County Youth Bureau, with input from OCDOH, also produces and maintains a comprehensive Children, Youth, and Family Services Directory. This directory is updated annually and includes information on health, education, social, recreation, transportation, and human services and programs. The directory is available online at www.orangecountygov.com. Exhibit 3.1 includes many of the organizations and agencies with which OCDOH staff work in a leadership capacity (advisory board, task force member, etc.) and identifies our major partners in service delivery to county residents. A complete listing of OCDOH staff affiliations with community, voluntary, and official agencies is provided at the end of this Section as Exhibit 3.2. OCDOH works collaboratively with a host of state, county, and local agencies, hospitals, health centers, health providers, CBOs and FBOs in planning and assessing community health needs. Health Services Gaps & Unmet Needs The health care needs of Orange County residents impacted by the barriers to health care access are described in Section I-B Access to Care. As part of the collaborative CHA/CSP planning process, Health Town Meetings were conducted in each of the county s four planning regions. These meetings were hosted by the hospitals and medical centers in each region and provided a forum to gain additional insight and input from community stakeholders on priority health needs and gaps in health-related programs and services. Representatives from the FQHCs serving county residents facilitated the discussion of community health issues. The following summarizes the primary unmet needs identified in Health Town Meetings and Resident and Agency/Provider Surveys of Local Health Needs. (See Section IV for further description of survey methodology). These needs focus primarily on access to and availability of primary and specialty health care services and community disease prevention and health promotion programs. A universal concern expressed was a lack of resident and provider awareness of available programs and services, and the need for a realtime centralized clearinghouse for county residents and providers to obtain up-to-date information on health-related programs and services. There is increasing need for primary medical care services for uninsured and underinsured persons in Orange County. The aging out of established primary care/family practice providers was a concern expressed in many communities. Enhance public transportation systems to improve access to health care services throughout the county. Although hospitals, medical centers, and community health centers in the county are serviced by public transportation in key urban areas, transportation to specialty health care services is an area for improvement. Access to care would be improved by expanded hours and days of operation by medical and dental health care providers serving the uninsured and working poor, i.e., more evening and weekend hours. The recent economic downturn has exacerbated this issue, as working adults are increasingly reluctant to miss work to attend to non-emergent personal and family health needs, due to employment concerns. Availability of and accessibility to specialty treatment services within the county is a concern, especially for Medicaid-insured, underinsured, and uninsured residents. Community Health Centers and private providers report delays in securing appointments for pediatric, adolescent and adult patients in need of evaluation, diagnosis and treatment by medical, dental, and substance abuse/mental health specialists. Changing demographics have resulted in increased demand for fluency in other languages (primarily Spanish) and improved cultural awareness among health care providers in Orange County. The significant increase in the adult population ages 65 and over impacts the demand for all types of health care services preventive, primary, and specialty. Prevention of early sexual activity and unintended pregnancy, tobacco and substance use/abuse, mental health issues and self-destructive/risky Orange County Community Health Assessment 2010-2013 Section III 1

behaviors in youth emerged as concerns. This includes early identification and comprehensive support services for high risk children, adolescents, and their families and coordination with schools as well as providers and community agencies. There is the need to enhance access at multiple points of care, including hospital emergency rooms, to information and enrollment in Medicaid Managed Care, Family Health Plus, Child Health Plus, and FQHC services to improve utilization of these programs and services. There is a need to better address the underlying causes of chronic diseases by further developing and expanding the existing health education and primary prevention services provided by OCDOH, health providers, and community agencies. Programs should target high prevalence communities using evidence-based models and systemic approaches, i.e., NYS Cardiovascular Health Plan; Diabetes Prevention and Control Program; Eat Well, Play Hard; Strategic Health Alliance for Health; and the National Diabetes Collaborative. Improved accessibility to and utilization of early detection and screening services for chronic diseases, especially by low-income, minority populations was an identified need. Enhanced research and surveillance related to major health concerns in the county (e.g., Obesity, Asthma) to better assess needs and prioritize programs and services. Discussion of program and service needs by CHA Service Area follows. These needs are further discussed in the context of the three selected Prevention Agenda Priority Areas in Section IV Local Health Priorities. Family Health & Related Access to Care Needs Many children and adults who lack access to primary and preventive health care have family incomes that are too high for Medicaid eligibility, but also are so low that paying for medical costs becomes prohibitive (the working poor). Many low wage earners have employers that do not offer health insurance, or offer plans with large deductibles and co-payments that present major barriers to care. Other barriers to primary care caused by inadequate income include the lack of transportation, limited hours of operation at service providers, the inability to locate providers enrolled in Medicaid Managed Care or Child Health/Family Health Plus, or lack of knowledge about these and other publicly-supported health insurance programs (these and other barriers are reviewed in Section I-B). Health and social problems prevalent in Orange County adolescents are also common to other HVR and NYS adolescents (see Section I-A3 Health Status of County Residents). Although the teen pregnancy rate in Orange County has been declining over the past several years, it remains above the average for the state and region. Recent data compiled by MISN indicates an increase in pregnancy rates in teens ages 15-17 and 18-19 in the county from 2006-2007; teen birth rates in the county s three cities remain elevated. Rates for youth DWI and drug arrests also exceed Upstate averages. The reported lack of community-based prevention and treatment programs for adolescents compounds this problem. The availability of preventive and restorative dental services at the FQHCs serving the county has improved access; however a shortage of specialty dental services for low income children and adults throughout the county was reported. The need for dental education to encourage preventive care for all residents, with or without insurance coverage, was highlighted. Lead testing rates within the county indicate that providers are not complying with New York State mandated universal screening. There is a continuing need for public and health provider education about universal testing of young children for lead in accordance with New York State Public Health Law, with an emphasis on reaching providers in areas with the highest prevalence of elevated BLLs. Despite the overall favorable reproductive health of Orange County women, populations at risk still exist: women living in poverty, teenagers, Black/African Americans and recent immigrants. Early and adequate prenatal care correlates with improved birth outcomes. The percentage of women receiving early prenatal care in the county is below that for the region and state, and teens and minorities are the least likely to receive early care. Language and cultural barriers continue to hinder access to care. Reproductive health/family planning services are critical to family health and stability. Lowincome women and teens are less likely to seek and to receive family planning services, although these women are at greater risk of poor pregnancy outcomes than are older and more affluent women. In general, the newly-arrived immigrant population, particularly those from Mexico and South/Central American countries, constitutes a large low-income population group in the county, owing to language barriers and limited employability skills. Many undocumented immigrant adults are either ineligible or choose to not participate in government programs for health care and financial assistance due to deportation concerns. The immigrant population in the county is served primarily by the Community Health Centers, where a high proportion of users are Hispanic/Latino. The comparatively high rates of hospitalization for three ambulatory sensitive conditions (ASC) asthma, pneumonia, and gastroenteritis - for young children in the county and the excess hospitalization rates for Prevention Quality Indicator chronic disease composites in the county s three cities require further evaluation. Both of these indicate a lack of access to primary care for prevention and early detection and treatment of these conditions. Mortality rates for unintentional injuries, especially motor vehicle accidents that involve alcohol, indicate the need for preventive efforts by community and law Orange County Community Health Assessment 2010-2013 Section III 2

enforcement agencies to reduce the incidence of driving under the influence, with an emphasis on combating underage drinking. Disease Prevention and Control Service Needs The adverse effects of tobacco use have been well documented in persons who smoke and in nonsmokers exposed to second hand smoke. Smoking accounts for at least 30% of all cancer deaths (80% of lung cancer deaths), and is a major contributor to other chronic diseases such as heart disease, asthma, COPD/CLRD, and to low birthweight. Comprehensive outreach and education campaigns, such as those conducted by OCDOH s Tobacco Prevention and Control Programs, are necessary to continue to reduce smoking, especially among teenagers (see Section I-C Behavioral Risk Factors). Obesity is an increasing problem for all Orange County and NYS residents, but is of special concern in children and teens because it not only increases the risk of chronic diseases later in life, but can result in psychological and social difficulties at an especially sensitive time in their development. As discussed in Section I, Populations at Risk, NYSDOH s Student Weight Status surveillance initiative will provide critical data to target prevention efforts and monitor progress over time. Establishing healthy eating and activity habits as lifelong practices are critical to prevention of overweight and obesity throughout life. In spite of improvements in cardiovascular and cancer mortality over the past several years, disparities in incidence and mortality rates in minorities and the medically underserved persist. In Orange County, Blacks/African Americans have the highest overall mortality rate (all causes) and mortality rate for cardiovascular diseases compared to Whites and Hispanic/Latinos. Promotion and adoption of healthy lifestyle practices are critical to reducing the incidence of CVD and cancer, as well as most chronic diseases. Black/African Americans and Hispanic/Latinos have been identified to have lower screening rates in the Hudson Valley region for breast, colon, and prostate cancers. (American Cancer Society Region 7 Cancer Control Priorities & Priority Population Summary for FY 2004) Early detection through routine screening is critical to improving cancer survival rates. Data on early stage diagnosis from the NYS Cancer Registry for 2001-2005 support the need to promote and enhance early detection and screening services in the county, especially those targeted to women. Rates of hospitalization in both children and adults for asthma indicate the need for enhanced preventive education services by health care providers and through community based initiatives. Although not included in as priority needs, additional areas of concern related to communicable disease prevention and control follow: Rates of sexually transmitted diseases remain disproportionately high in low income areas. Therefore, STD services have been directed to residents in high poverty areas. Persons living in poverty may have less access to primary care, be less compliant about treatment regimens, be more likely to have substance abuse problems, and exhibit other risky behaviors, such as anonymous sex and prostitution, including exchanging sex for drugs. Homelessness poses additional problems, because contact tracing and other epidemiologic investigations, such as partner notification, become extremely difficult. The proportion of women of reproductive age diagnosed with gonorrhea and chlamydia is increasing. Therefore, asymptomatic screening for sexually transmitted diseases (gonorrhea, chlamydia and syphilis) and educational efforts should continue to be targeted to women of reproductive age. Educational messages should be age and culturally appropriate. Tuberculosis occurs disproportionately in Blacks/African American and Hispanic residents in the county, especially in foreign-born persons living in poverty. As previously discussed, Orange County has a favorable rate of completion of treatment. HIV infection is increasingly spreading to females in Orange County through heterosexual contact and injectable drug use. The Black/African American and Hispanic/Latino populations are overrepresented in AIDS cases in the county. The primary risk behaviors for HIV/AIDS transmission are injectable drug use and unprotected sex with partners in high risk groups. Cases of vaccine preventable disease continue to be reported in Orange County each year; most notable is the increased incidence of Pertussis. Infants and toddlers of recent immigrants and uninsured or underinsured children are at high risk for delayed immunization, yet these populations are often the most difficult to reach. Barriers such as fear of deportation, lack of education about the importance of vaccines, cultural differences, and lack of transportation still prevent these families from accepting or accessing care. Ongoing, intensive outreach efforts are necessary to inform, educate, and immunize this population. The declaration of pandemic influenza H1N1 in June 2009 necessitates timely and coordinated efforts among public, community, and private health providers to assure vaccination coverage for both seasonal and pandemic flu, based on vaccine supply and priority groups as established by CDC and NYSDOH. Orange County Community Health Assessment 2010-2013 Section III 3

Exhibit 3.1 ORANGE COUNTY DEPARTMENT OF HEALTH RESOURCE GUIDE FOR HEALTH AND RELATED SERVICES* ORANGE COUNTY OFFICES: Orange County Department of Health 1887 County Building, 124 Main St., Goshen, NY 10924 Jean M. Hudson M.D., M.P.H., Commissioner of Health Commissioner/Administration: 845-291-2332 Community Health Outreach: 845-568-5237 Early Intervention: 845-291-2333 Environmental Health: 845-291-2331 Nursing: 845-291-2330 WIC: 845-291-2044 The Orange County Department of Health monitors and protects the health status and health needs of the residents of the County. The Department provides public health services throughout Orange County. Activities include public health nursing services upon referral from a physician, long-term care in the home for homebound patients, tuberculosis and sexually transmitted disease clinics which provide diagnosis and specific treatment, general pediatric clinics which emphasize preventive care, HIV/AIDS clinics that offer diagnosis and counseling and referral for treatment, communicable disease control, immunizations, sanitary inspections, engineering reviews, screening and monitoring services for at-risk infants and toddlers, early intervention and pre-school special education services for children, community health outreach, injury prevention, health education, emergency medical services coordination, epidemiologic analysis, nutrition services, WIC (Women, Infant and Children's nutrition program), maternal support for newborn care, and provision of financial support for medical care of physically handicapped children and adult polio clients. Fee: None (Exception Fees charged for Adult and Traveler Immunization Clinics). Orange County Department of Social Services Box Z, 11 Quarry Road, Goshen, NY 10924 845-291-2800 The Orange County Department of Social Services provides temporary help to eligible individuals and families with social service and financial needs in order to assist them with leading safe, healthy and independent lives. Orange County Office for the Aging 18 Seward Avenue Middletown, NY 10940 845-615-3700 The Orange County Office for the Aging is committed to meeting the special service needs of Orange County s senior population, their families and friends who care for them. Orange County Office for the Aging offers services, either directly or through sub-contracts, designed to maintain the quality of life of those aged 60 and over. Orange County Youth Bureau 18 Seward Avenue Middletown, NY 10940 845-615-3620 Carol Chichester, Director The Youth Bureau s mission is to promote youth development, to coordinate services for all youth in Orange County and to develop and fund local programs. Fee: None. Newburgh Child & Family Clinic Orange County Department of Mental Health 141 Broadway, Newburgh, NY 12550 845-568-5260 Broad-based staff specializing in individual family and group therapy. Psychiatric evaluations. Medication provided (when necessary) to active clients. Fee: Sliding scale fee, Medicaid, other insurance. * Publication date - August 2009. Contact agencies by phone or web/email addresses provided for up-to-date information regarding programs, services, and fees. Orange County Community Health Assessment 2010-2013 Section III 4

ORANGE COUNTY OFFICES (Continued): Orange County Residential Health Care Facility 3 Glenmere Clove Road, Goshen, NY 10924 845-291-4740 Kenneth A. Carter, Administrator The Department of Residential Health Care Facility is a 520-bed skilled nursing facility providing quality long and short-term care for those in need of 24-hour nursing care due to chronic illness, injury or advancing age. Physical, Occupational & Speech therapies are provided, as well as Respite and Hospice care. Private & Semi-private rooms are offered. Fee: Private funds, Medicare, and Medicaid are accepted. Orange County Department of Mental Health 30 Harriman Drive, Goshen, NY 10924 845-291-2600 Newburgh: 845-568-5260 Port Jervis: 845-858-1456 24 hour Helpline Health & Human Services/Referrals & Resources within Orange County/24 hour rape & crisis hotline: 1-800-832-1200 Web: www.mhaorangeny.com The Orange County Department of Mental Health exists to ensure that quality mental health, developmental disabilities and chemical dependency services are accessible to all the residents of Orange County. Counseling, support groups for families and individuals. Fee: Sliding scale fee, Medicaid and other insurance. HOSPITALS: Orange Regional Medical Center Arden Hill Campus: 4 Harriman Drive, Goshen, NY 10924 845-294-5441 Horton Campus: 60 Prospect Avenue, Middletown, NY 10940 845-343-2424 Web: www.ormc.org St. Luke s/cornwall Hospital St. Luke s Campus: 70 Dubois Street, Newburgh, NY 12550 845-561-4400 Cornwall Campus: 33 Laurel Avenue, Cornwall, NY 12518 845-534-7711 Web: www.stlukescornwallhospital.org Bon Secours Community Hospital 160 East Main Street, Port Jervis NY 12771 845-856-5351 Web: www.bonsecourscommunityhosp.org Saint Anthony s Community Hospital 11 Grand Street, Warwick, NY 10990 (845) 986-2276 Web: www.stanthonycommunityhosp.org Keller Army Community Hospital 900 Washington Road West Point, NY 10996 845-938-5169 Web: www.kach.amedd.army.mil Orange County Community Health Assessment 2010-2013 Section III 5

HEALTH CENTERS: Hudson River Health Care 75 Orange Avenue, Walden, NY 12586 845-778-2700 Alamo Clinic: Box 888 Pulaski Highway, Goshen, NY 10924 845-651-2298 Dentistry, Outreach Services, WIC (Supplemental nutrition program for pregnant women, infants and children), Women s Health, Children and Adolescents, Prenatal Care, Health Screenings, HIV Counseling and Testing, Immunization and Vaccinations, Family Planning, Health Education. Fee: Sliding scale fee, Medicaid, other insurances. Community Health Education Center Orange Regional Medical Center 110 Crystal Run Road, Middletown, NY 10940 1-888-321-6762 Provides patient and family education, community classes, support groups and health screenings for Orange County residents. Middletown Community Health Center Women s Health Services 10 Benton Avenue, Middletown, NY 10940 845-343-8838/845-342-6601 14 Grove Street, Middletown, NY 10940 845-344-2273 140 Hammond Street, Port Jervis, NY 12771 845-858-7280 Provides health and medical services to women, including gynecology and prenatal care services. (Formerly United Community Health Center) 99 Cameron Street, Pine Bush, NY 12566 Mailing address: PO Box 987, Middletown 10940 845-744-2067 Adult and Pediatric medical care, gynecology/family planning, confidential HIV testing and counseling, testing for sexually transmitted infections (STIs), pregnancy counseling, case management, nutrition and social work services, podiatry, bilingual patient advocacy. Fee: Sliding scale fee, Medicaid, other insurances. Orange Regional Medical Center 4 Harriman Drive, Goshen, NY 10924 845-291-5441 60 Prospect Avenue, Middletown, NY 10940 845-343-2424 Services provided: Audiology, Alcohol and Substance Abuse, Behavioral Health Services, Cancer Care, Cardiac Care, Diabetes Treatment, Diagnostic Imaging, Emergency Medicine, Maternity/OB-GYN. Outpatient Services: Pediatrics, Pulmonary Services, Rehabilitative Medicine, Surgery and Vascular Lab, Wound Care Center. Fee: Medicaid, other insurance. Middletown Community Health Center 21 Orchard Street, Middletown, NY 10940 845-343-7614 Adult medicine, Pediatric medicine, Nutrition counseling, substance abuse assessment, education and referral, HIV and sexually transmitted disease counseling and testing, Podiatry services, Women s Health Services, Family planning, Dentistry. Fee: Sliding scale fee, Medicaid, other insurances. Greater Hudson Valley Family Health Center, Inc. 3 Washington Center, Newburgh, NY 12550 845-565-3138 Non-profit organization providing comprehensive health care services for the community at large, with a special emphasis on the medically underserved population. Services include: Internal Medicine, Pediatrics, Gynecology/ Women s medical, Podiatry, Dental, AIDS/HIV Counseling, testing and case management, Community Education, Family planning, MOMS programs, Immigration physicals, Lead Screening, Mobile Health Unit, Nutrition Counseling, On-site Laboratory, On-site Pharmacy, Referral services, Ryan White Title II HIV Care Network-Mid-Hudson Region, Social Services and Substance Use Counseling. Fee: Sliding scale fee, Medicaid, other insurance. Orange County Community Health Assessment 2010-2013 Section III 6

HEALTH CENTERS (Continued): McAuley Health Center 140 Hammond Street, Port Jervis, NY 12771 845-858-7280 Family practice, Pediatrics, Orthopedics, Pain management, GYN services. Fee: Sliding scale fee, Medicaid, other insurances. United Community Health Center 99 Cameron Street, Pine Bush, NY 12566 845-744-2067 Adult and Pediatric medical care, gynecology/family planning, confidential HIV testing and counseling, testing for sexually transmitted infections (STIs), pregnancy counseling, case management, nutrition and social work services, bilingual patient advocacy. Fee: Sliding scale fee, Medicaid, other insurance. Inspire Cerebral Palsy Clinic 2 Fletcher Street, Goshen, NY 10924 845-294-8806 Services: Audiology, Dentistry, Early Intervention, Neuropsychology, Occupational Therapy, Physical Therapy, Service Coordination, Social Work, Speech/ Language Pathology and Therapeutic Pool. Fees: Medicare, Medicaid and other insurances. HEALTH EDUCATION: Warwick Area Migrant Community, Inc. Farmworkers Community Center (Alamo Clinic) PO Box 607, Goshen, NY 10924 845-651-4272 Offers services for the prevention and education of alcohol, tobacco and other drugs, offers medical clinic, dental clinic, job services, AA meetings, referral to ATOD treatment with transportation, food pantry, free clothing room and recreation program for children. Fee: None. Cornell Cooperative Extension 1 Ashley Avenue, Middletown, NY 10940 845-344-1234 Web: www.cce.cornell.edu/orange Educational programs which include parenting, home economics, agriculture, 4-H Youth development, energy, food and nutrition, money management, integrated pest management and watershed usage. Fee: None. Orange County Community Health Assessment 2010-2013 Section III 7

HEALTH EDUCATION (Continued): Hospice of Orange in Hudson Valley 800 Stony Brook Court, Newburgh, NY 12550 845-561-6111 This is a not-for-profit, community based program of home care which treats the terminally ill patient and family as a unit. Hospice services are coordinated through an interdisciplinary team, which includes nurses, social workers, physicians, volunteers and related therapists. Hospice provides supportive care to meet the special needs arising out of those physical, psychological, spiritual and economic stresses which are experienced during the final stages of illness, dying and bereavement. Services not limited to cancer patients. Fee: Medicaid, Medicare, other insurance. AIDS Related Community Services (ARCS) 473 Broadway, Newburgh NY 12550 845-562-5005 Provides case management (with 24-hour coverage), community education, crisis intervention, HIV/AIDS prevention in drug treatment programs, transportation program, volunteer buddy program, hospital visitors, alcoholism and substance abuse HIV/AIDS education and counseling services, prison services, jail services, HIV antibody counseling and testing (Newburgh office), referral and partner notification, individual, couples and family counseling, support groups, advocacy, referrals (medical, dental, legal, funeral services), educational programs for clients, professionals and the community including: behavior change, risk education, basic HIV/AIDS information and medical updates. Services are provided for Dutchess, Orange, Putnam, Rockland, Sullivan, Ulster and Westchester counties. Bilingual services available. Fee: Fees vary according to services, sliding scale fee, Medicaid and other insurance. Orange County Community Health Assessment 2010-2013 Section III 8

HEALTH EDUCATION (Continued): American Red Cross-Orange Chapter 55 Main Street, Goshen, NY 10924 845-294-9785 Web: www.nyredcross.org Provides primary disaster relief, limited rent and utilities program, comprehensive health trainings and education which includes: child safety education (for kindergartners-adult) babysitting certification, First Aid/CPR and HIV/AIDS. Fee: None. American Cancer Society- Hudson Valley Region- Orange Unit 419 East Main Street, Middletown, NY 10940 845-343-5612 1-800-233-5049 Web: www.cancer.org Information and education on different types of cancer, Cancer support groups. American Heart Association 419 East Main Street, Middletown, NY 10940 845-342-1115 Information regarding heart disease, stroke, cholesterol, blood pressure, nutrition, exercise and CPR training. Fees vary according to services and class. American Lung Association of the Hudson Valley 35 Orchard Street, White Plains, NY 10603 914-949-2150 Web: www.alahv.org Information and education on fighting lung disease and promoting lung health. Fee: None. Planned Parenthood of the Mid-Hudson Valley 280 Broadway, Newburgh, NY 12550 (845) 562-5778 Web: education@ppmhv.org Provides Community Education programs for parents, teens, agencies, schools and faith communities that will provide information and skills to create a world where sexuality is respected and valued. Planned Parenthood Mid-Hudson Valley's Education Department provides reality based, interactive programs rooted in scientifically accurate information about sexuality and reproductive health. Resources are always available to provide parents, teachers and individuals with the tools necessary to promote sexuality education. Fee: None. Orange County Community Health Assessment 2010-2013 Section III 9

COALITIONS: Hudson Valley Asthma Coalition American Lung Association of New York State 3 West Main Street, Suite 208, Elmsford, NY 10523 914-347-2094, Ext. 20 Asthma education and prevention programs. Fee: None. Healthy Orange 130 Broadway, Newburgh NY 12550 845-568-5226 Danielle Moser, Senior Public Health Educator Web: www.orangeountygov.com Email: dmoser@orangecounty gov.com Healthy Orange is an initiative coordinated by the Orange County Department of Health which addresses three core areas for health promotion and disease prevention in county residents - improved nutrition, increased physical activity and movement, and a tobacco-free lifestyle. The Healthy Orange Team (HOT) is a collaborative union of agencies within the county that work together to promote health and wellness in county residents of all ages. Fee: None. Orange County Eating Disorders Coalition Mental Health Association in Orange County 845-295-7422 Helpline: 1-800-832-1200 Web: www.mhaorangeny.com Provides treatment and referral lists, on-line screening program, education and prevention. Fee: None POW R Against Tobacco 35 Orchard Street, White Plains, NY 10603 1-888-841-POWR Web: www.powragainsttobacco.org POW'R Against Tobacco is a four county coalition that was founded in 1992 to reduce the risk of tobaccorelated diseases by lowering the prevalence of tobacco use in Putnam, Orange, Westchester and Rockland Counties. POW'R is funded by a grant from the New York State Department of Health. Since 1992, the Coalition has been working in the community to meet four goals: reduce exposure to secondhand smoke, prevent and reduce tobacco use in under-served communities, promote quitting among adults and youth and prevent youth from using tobacco products. Fee: None. Diabetes Prevention and Control Program of Orange County 888-877-9655 Email: www.diabetesorangecounty.org A coalition of health care organizations and groups focused on preventing diabetes and helping those who already have diabetes. Provides educational programs throughout Orange County in addition to resources on all types of diabetes. Also provides information on prevention, control and upcoming programs, as well as information on endocrinologists in the county. Fee: None Orange County Parenting Coalition 18 Seward Avenue, Middletown, NY 10940 845-344-1234 Web: www.cce.cornell.edu/orange A group comprised of parents, teachers, individuals and agency representatives who understand parenting to be a learned skill. Dedicated to ensuring that all parents and caregivers have access to programs and services to further develop. Fee: None. Orange County Community Health Assessment 2010-2013 Section III 10

COALITIONS (Continued): Orange County Perinatal Consortium 200 Route 32, PO Box 548, Central Valley, NY 10917 845-928-7448 This multidisciplinary agency group meets on a quarterly basis throughout the year and works to increase healthy birth weights and maternal health. Trainings, presentations, and referrals are given by experienced consortium partners on an as needed basis. Bi-yearly community baby showers are also sponsored by this group. Fee: None. Mid Hudson Adult Immunization Coalition 845-291-4281 Through collaboration with other members, this coalition works for Orange County residents to prevent disease and disability, promote health and safety, and protect our residents from risks and threats to our water, food and air supplies, and from other potential health hazards. Fee: None. Port Jervis Community Agency Coalition Care of: Connections Program at Bon Secours Community Hospital 160 East Main Street, Port Jervis, NY 12771 1-888-921-5594 The Port Jervis Council of Community Agencies meets every other month on the third Wed. at 1pm at the First Assembly of God Church in Port Jervis. The Council provides an opportunity for agencies/organizations to get together on a regular basis and network. The sharing of information is extremely important for those human service agencies to be able to serve their target populations better. Fee: None. Orange County Teen Pregnancy Prevention Coalition/Newburgh Teen Pregnancy Prevention Coalition 200 Route 32, PO Box 548, Central Valley, NY 10917 845-928-7448 Meetings are held on a monthly basis to discuss pregnancy prevention strategies, plan outreach events, and invite agencies that are willing to collaborate with the coalition and learn about pregnancy prevention services available in the county. Fee: None. Orange County Community Health Assessment 2010-2013 Section III 11

WOMEN S HEALTH: Newburgh Healthy Families 21 Grand Street, Newburgh, NY 12550 845-562-7244 Home visiting service offering support and information to expectant parents, new parents and their babies in the 12550 and 10940 zip codes. Fee: None. Maternal Infant Services Network 200 Route 32, Central Valley, NY 10917 845-928-7448 Mother s Helpline 1-800-453-4666, 9-5, M-F The purpose of MISN is to ensure that every woman of childbearing age and her family have access to the full range of preventive and primary health care, social, nutritional and educational services for their children. Fee: None. Catholic Charities- Maternity & Adoption Services 280 Broadway, Newburgh, NY 12550 845-534-4894 Offers maternity and adoption services to married & unmarried parents. Services include: counseling, medical care, housing assistance, future planning for an unborn child, exploration of adoption as an option and guidance through the adoption process. Fee: Sliding scale. Planned Parenthood of the Mid-Hudson Valley, Inc. 7 Coates Drive, Suite 4, Goshen, NY 10924 845-294-8831 532 Blooming Grove Turnpike, New Windsor, NY 12553 845-562-7800 91 Dubois Street, Newburgh, NY 12550 845-562-5748 40 Grove Street, Middletown, NY 10940 (845) 343-4432 43 Main Street, Walden, NY 12586 845-778-2220 Health Education Resource Center 280 Broadway, Newburgh, NY 12550 26 West Street, Newburgh, NY 12550 845-562-3098 Web: www.ppmhv.org Sexual health education, Women s health care providing full GYN exams, birth control methods, pregnancy testing, HIV testing, sexually transmitted infections screening, Family planning, education and training, Teen clinics, TASA case management program. Services confidential. Fee: Sliding Scale Fee, Medicaid and insurance accepted. Birthright of Orange County 40 Grove Street, Middletown, NY 10940 845-343-3121 Services include free pregnancy tests, help planning for baby, referrals for Medical assistance. (Call for hours) Fee: None. Safe Homes of Orange County and Orange County Family Justice Center PO Box 649 Newburgh, NY 12550 1-800-503-4673 (24 hours/day) Advocacy, Support, Shelter, 24- hour hotline, and referral services for families affected by intimate partner/family violence. TASA case management services. Fee: None. Orange County Community Health Assessment 2010-2013 Section III 12

WOMEN S HEALTH (Continued): Project LIFE 172 First Street, Newburgh, NY 12550 845-569-9334 Tier 2 Family Shelter, Referrals made from Public Assistance. Fee: None. My Choice Pregnancy Care Center 388 Blooming Grove Turnpike, New Windsor, NY 12553 845-294-1812 Provide pregnancy tests, ultrasounds and counseling to consider pregnancy options. STI testing is also completed. Fee: None. Child Care Council of Orange County 40 Matthews Street, Goshen, NY 10924 845-294-4012 Other Areas: 1-800-827-1751 Web: www.childcarecounciloc.org The Child Care Council of Orange County is a private, non-profit organization that functions to develop available and accessible quality child care for all children regardless of income level, or cultural back-ground. Its purpose is to expand and enhance childcare. Fee: None. YWCA Orange County Cancer Services Partnership Provides breast, colorectal and cervical cancer screening and follow-up care to under-income, underserved women between the ages of 18-65. Women over the age of 40 are able to receive free mammograms. Fee: None. YOUTH SERVICES: RECAP, Inc.-Youth Program 119 123 East Main Street, Middletown, NY 10940 845-343-9944 Serves low-income people by offering GED, ABE, ESL, Computer literacy, parenting classes, job readiness, employment services, case management, post employment and job retention youth program. Fee: None. Head Start of Eastern Orange 49 Gidney Avenue, Newburgh, NY 12550 845-562-0380 A comprehensive program designed to meet the social, emotional, health, nutritional and educational needs of pre-school children and supportive services for families. Fee: None. RECAP/Western Orange County Head Start North Congregational Church 157 Linden Avenue, Middletown, NY 10940 845-343-4191 31 West Main Street, Port Jervis, NY 12771 845-856-6821 A comprehensive program designed to meet the social, emotional, health, nutritional and educational needs of pre-school children and supportive services for families. Fee: None. Family Empowerment Council, Inc. 225 Dolson Avenue, Suite 403, Middletown, NY 10940 E-mail: kmallin@familyempowerment.org 1-888-343-8181 Web: www.familyempowerment.org Educational Advocacy Program will enable youth to remain in school, return to school or pursue constructive alternatives to high school. Program will provide advocacy to parents who need assistance with proper school placement and/or evaluation. Fee: None Orange County Community Health Assessment 2010-2013 Section III 13

YOUTH SERVICES (Continued): Liberty Partnership Program 54 Grand Street, Newburgh, NY 12550 845-562-2469 Personal and family counseling, College and career counseling, Academic support, Workforce preparation and Cultural enrichment to students grades 7 through 12. Fee: None Glenn E. Hines Memorial Boys & Girls Clubs of Newburgh, Inc. 285 Liberty Street, Newburgh, NY 12550 845-561-4936 E-mail: nmcal285@aol.com Comprehensive recreation and youth service program targeting minority and disadvantaged youth. This fulltime, structured program includes social, cultural and educational programs. Fee: Sliding scale fee. A Friend s House Youth Shelter 38 Seward Avenue, Suite 700, Middletown, NY 10940 845-343-0968 E-mail: ehgrhy@citlink.net Provides shelter for runaway and homeless teens. Fee: None. LINKS Aftercare Program 38 Seward Avenue, Suite 300, Middletown, NY 10940 E-mail: ehgceo@citlink.net Provides case management services for youth ages 16-21 years of age who reside within Orange County. Case managers make referrals to corresponding agencies, assist with basic needs such as food and clothing, education, advocacy and employment. They also help formulate realistic goal plans for the young person. Fee: None. Youth Street Outreach 38 Seward Avenue, Suite 700, Middletown, NY 10940 845-343-0970 Serves youth 12-21 years of age. Will listen to and assist with any issues the youth may have and provide referrals to agencies that can help. Fee: None West Point Youth Services Bldg 500, Washington Road, West Point, NY 10996 845-938-3727 Offers youth programs to youth in the West Point community and Highland Falls School District. National Runaway Switchboard/Adolescent Suicide Hotline 1-800-621-4000 Crisis intervention, information and referrals Newburgh Youth Bureau 123 Grand Street, P.O. Box 1030, Newburgh, NY 12550 845-565-1213 The Newburgh Youth Bureau determines the needs of youth in the City of Newburgh, inventories City youth resources capable of meeting these needs, plans and encourages the development of new services essential for meeting the needs of youth. Fee: None. Orange County Community Health Assessment 2010-2013 Section III 14

YOUTH SERVICES (Continued): Agri-Business Child Development Middletown ABCD 47 Academy Avenue, Middletown, NY 10940 845-956-2270 Florida ABCD P.O. Box 187, Edward J. Lempka Drive, Florida, NY 10921 845-651-2270 Comprehensive child-development and family support services related to education, nutrition, health/dental care, parent involvement, social services, mental health and services to children with disabilities. Fee: Qualification for services- call for information, sliding scale. CASE MANAGEMENT: TASA (Teenage Services Act) 40 Grove Street, Middletown, NY 10940 845-344-2139 91 Dubois Street, Newburgh, NY 12550 845-565-0227 26 West Street, Newburgh, NY 12550 845-562-0814 Offers case-management services for pregnant, parenting and at-risk teens under 21. TASA Case Managers work directly with pregnant and parenting teens to assist them in achieving selfsufficiency. The focus is on employment, education, health care, housing, nutrition and advocacy. Fee: Medicaid Rural Opportunities 130 Dolson Avenue, Middletown, NY 10940 845-343-0771 Supportive services, counseling, employment and training opportunities, food and nutrition services and pesticide training. Fee: None. Inspire Cerebral Palsy Clinic 2 Fletcher Street, Goshen, NY 10924 845-294-8806 Services: Audiology, Dentistry, Early Intervention, Neuropsychology, Occupational Therapy, Physical Therapy, Service Coordination, Social Work, Speech/ Language Pathology and Therapeutic Pool. Fees: Medicare, Medicaid and other insurances. Adolescent Pregnancy Prevention 280 Broadway, Newburgh, NY 12550 845-562-0100 91 Dubois Street, Newburgh, NY 12550 845-562-5748 Case management services to high risk pregnant or parenting teens that are not eligible for other funded case management services. Fee: None. Catholic Charities P.O. Box 64, 185 Liberty Street, Newburgh, NY 12550 845-561-3452 Social work counseling of individuals and families under stress due to personal problems or environmental pressure. Counseling for unwed mothers and adoption services. Fee: Sliding scale fee Family Empowerment Council, Inc. 225 Dolson Avenue, Suite 403, Middletown, NY 10940 845-344-0027 Provides Medicaid Service Coordination, Residential Rehabilitation Services, Respite Services, Day-time Rehabilitation Program, Personal Care Aid Service, Educational Advocacy, and Network Program that assists with troubled youth. Fee: Medicaid Orange County Community Health Assessment 2010-2013 Section III 15

CASE MANAGEMENT (Continued): Crystal Run Village 601 Stony Ford Road, Middletown, NY 10941 845-692-4444 Provides Residential Services, Supported Employment/Job Placement, Service Coordination, Village Care, Mobile Work Crew, In-home Respite, Mental Health Services, Respite House, Open Vistas Day Habilitation, In-home Residential Habilitation and Recreation Programs for people with disabilities. Fee: Medicaid, Medicare, other insurance, sliding scale fee for some services. Orange County AHRC Admin Office, 249 Broadway, Newburgh, NY 12550 845-561-0670 Web: www.orangeahrc.org Provides training, housing and employment for the developmentally disabled to become independent, productive members of the communities. Informs the public of our clients needs and potentials. Provides help to the families of our clients. Fee: None Hamaspik of Orange County, Inc. 51 Forest Road, Suite 302, Monroe, NY 10950 845-774-7044 Intermediate care facility providing 24-hour intensive support with medical and/or behavioral services and training in daily living skills. Services include Occupational, Physical and Speech Therapies, Psychology, Social Work, Nursing, Nutrition and Recreation. Fee: Medicaid Jewish Family Services of Orange County JFS has two locations: 720 Route 17M, Middletown, NY 10940 845-341-1173 68 Stewart Avenue, Newburgh, NY 12550 845-562-8372 Provides individual and family mental health sessions. Provides at-home services, volunteer visits, and assistance to caregivers, and connections to community resources for adults. Provides educational and social programs for young people that help them feel valued and empowered, as well as offer support to their parents. Assists adults with developmental disabilities to realize full and encompassing lives both at work and within their communities. As funds allow, JFS provides a helping hand to families in need. Currently our Diane Finkelstein Families in Crisis Fund is dedicated to assisting families in obtaining food assistance as well as funds for rent, security deposits, and car repairs needed for transportation to work. MENTAL HEALTH: Mobile Mental Health Unit Occupations Inc. 1-888-750-2266 Web: www.occupations.org Mobile Mental Health Unit operates for those who need assistance outside normal working hours. Available 24 hours a day. Fee: None Family Counseling, Occupations, Inc. 16-24 Union Street, Middletown, NY 10940 845-343-5556 1-888-750-2266 21 Grand Street, Newburgh, NY 12550 845-562-7244 Provides outpatient mental health services, including diagnosis and treatment, psychiatric evaluation, medication (when necessary), individual, family, marital and group therapy. Bi-lingual services available. Fee: Medicaid, Medicare, sliding scale fee, insurance. Orange County Community Health Assessment 2010-2013 Section III 16

MENTAL HEALTH (Continued): Mental Health Association in Orange County 73 County Highway 108, Middletown, NY 10940 845-342-2400 Helpline: 1-800-832-1200 Web: www.mhaorangeny.com Hotlines, preventive programs, social clubs, resources. Help Line is a 24-hour, 7-day a week information/ referral and crisis intervention service. Fee: None. Arden Hill Behavioral Health Center 4 Harriman Drive, Goshen, NY 10924 845-294-2269 Work with children through geriatrics, Intake Assessment, Individual, Family, Couple and Play Therapy, Work with Horton Family Program, Psychiatric Evaluations, and Refers out for case management. Fee: Medicaid, other insurance. Occupations, Inc. Counseling Centers (4 Locations) 2001 Rte 17M, Second Floor, Goshen, NY 10924 845-294-6185 Web: www.occupations.org Each center provides outpatient mental health services, individual, family and group therapies, medication monitoring, psychiatric evaluation. Fee: HMO s, private insurance, Medicaid, Medicare. Call for an appointment. Pastoral Counseling Center 2139 Route 17K, Montgomery, NY 12549 845-361-2777 Services for issues including: depression, eating disorders, anxiety, bariatric follow-up, family, adolescent, couples and pre-marital therapy. Provides information/education, spiritual counseling and referral, Handicapped accessible. Fee: Sliding scale fee Alternatives Counseling Center 41 Dolson Avenue, Middletown, NY 10940 845-344-5549 Services all issues such as depression, addictions, abuse etc. in children and adolescents. For further assistance please call. Fee: Medicaid, Medicare, other insurance. Roosa Counseling Services 41 Dolson Ave, Middletown, NY 10940 845-342-5789 Web: www.myroosa.org Offers the full array of supportive counseling/ psychotherapy, Anxiety Disorders, Anger Management, Play Therapy, Teens in Crisis, Women in Abusive Relationships, Marriage and Couples Counseling, Depression, Mental Health Assessments. Fee: Insurance Children s Grieving Center 800 Stony Brook Court, Newburgh, NY 12550 845-561-6111 Provides a safe, neutral and private environment for grieving children and their families. Fee: None. Donations are accepted. Dispute Resolution Center P.O. Box 510, 14 Scotchtown Avenue, Goshen, NY 10924 845-294-8082 Ext. 21 Email: info@drcservices.org Programs include the Parent/Child Mediation Program for youth 13-18 years in conflict with their parents. The School-Based Conflict Resolution Program which trains youth kindergarten through college to mediate peer disputes, and the Court Appointed Special Assistants Program (CASA) which monitors the well-being of children removed to foster care due to abuse and/or neglect, birth to 16 years. Serves Orange, Putnam, Ulster, and Sullivan counties. Fee: None for most services, classes include a fee for materials. Orange County Community Health Assessment 2010-2013 Section III 17

SUBSTANCE ABUSE ISSUES: RECAP, Inc. - Addiction Program 40 Smith Street, Middletown, NY 10940 845-342-3978 Ext. 34 Serves people with alcohol/drug addictions, women/men with children, low income/homeless consumers. Fee: Medicaid, sliding scale fee, Insurance. Alcoholics Anonymous (AA) PO Box 636, Goshen, NY 10924 845-534-8525 If you or a member of your family has an alcohol problem, call the 24-hour answering service. This number will give you information regarding places, times, etc. of AA functions. Also, always listed in the Times Herald Record under "Bulletin Board:" Fee: None. RECAP Day Treatment Program PO Box 886, Middletown, NY 10940 845-342-5380 Web: www.recap.org E-mail: recap@recap.org Available 9:00 am to 1:30 pm. 5 day/week alcohol and drug rehab program. Individual and group therapy, films, discussions, lectures, recreation. Fee: Medicaid, sliding scale fee, Insurance. Alcoholism & Drug Abuse Council P.O. Box 583, 224A Main Street, Goshen, NY 10924 845-294-9000 E-mail: adac@adacinfo.com Information and referral about alcohol and substance abuse provided, Community, school and workplace prevention, training and education, Public awareness, film and resource library. Fee: None. Orange County Community Health Assessment 2010-2013 Section III 18

SUBSTANCE ABUSE ISSUES (Continued): Orange County Drinking Driver Program Orange County Community College 115 South Street, Middletown, NY 10940 845-341-4892 E-mail: rob.larkin@sunyorange.edu Education for convicted drinking driver evaluation and referral to rehabilitation and self-help, Defensive Driving classes, Pre-licensing. Fees: Defensive Driving classes: $40.00 Pre-licensing: $40.00 Al-Anon/Alateen 845-294-9999 For anyone who feels his/her life is being or has been affected by someone else's drinking. Meetings held throughout the County. Call answering service for information. Fee: None. Addiction Crisis Center 8 Seward Avenue, Middletown, NY 10940 845-343-1443 Non-medical detox, Open 24 hours a day, 7 days a week. Services provided regardless of insurance. Underage Drinking Hotline 866-Under-21 Enables the public to anonymously report underage sale and consumption of alcohol. Fee: None. Orange County Stop DWI P.O. Box 583, Goshen, NY 10924 845-294-9090 Web: www.orangecountystopdwi.com Promotes prevention education and training, distributes literature, Comprehensive program to eradicate drinking, drugging and driving. Programs encompass enforcement, prosecutions and treatment. Victims Impact Panel available through Orange County Stop DWI and it is also available for presentations. No fees, except for court appointed Victims Impact Panel. Orange Regional Medical Center Horton Family Program for Alcoholism/Chemical Dependency 420 East Main Street, Middletown, NY 10940 845-342-5300 Outpatient Chemical Dependency for Youth, Intensive Treatment Program for Adults, Women s Intensive Treatment, Outpatient Clinical Services, Adolescent/Family Treatment, Co-dependency Treatment, Comprehensive Psychosocial Evaluations, Court Evaluations, Employee/Business Evaluations, Consultations/Evaluations. Fee: Medicaid, Medicare, other insurance. Orange County Community Health Assessment 2010-2013 Section III 19

SUBSTANCE ABUSE ISSUES (Continued): Catholic Charities Gateway Center - NFA 46 Roe Street, Newburgh, NY 12550 845-569-0034 E-mail: cdepaolo@piusxii.org Services: Substance abuse clinic Fee: Insurances accepted. Call for information. Catholic Charities Chemical Dependency Program 21 Center Street, Middletown, NY 10940 845-343-7675 224 Main Street, Goshen, NY 10924 845-294-5888 520 Route 17M, Monroe, NY 10950 845-782-0295 280 Broadway, Newburgh, NY 12550 845-562-8255 17-19 Sussex Street, Port Jervis, NY 12771 845-856-6344 Outpatient drug abuse treatment services. Individual and group counseling. Specialized psycho-educational groups. Fee: Sliding scale fee, insurance, Medicaid. Middletown Addiction/Alcohol Crisis Center 38 Seward Avenue, Middletown, NY 10940 845-343-1443 24 hours/7 days per week Non-medical detox, Refers clients to the next phases of their treatment. Fee: None. Occupations, Inc. Continuing Day Treatment Centers 67 Windsor Hwy, New Windsor, NY 12553 845-562-6850 16-24 Union St Middletown NY 10924 845-343-5566 Web: www.occcupations.org Individual/group therapy, life skills training, substance abuse services, psychiatric rehabilitation, family support, medication, case management, flexible individual service and daily services available. Fee: Referral through DSS Catholic Charities Alcohol Program 520 Rt. 17M, Monroe, NY 10950 845-782-6600 Outpatient treatment for alcohol and drug abusers, their families and children. Individual and group counseling. Fee: Sliding scale fee, Medicaid, insurance Richard C. Ward Addiction Treatment Center 117 Seward Avenue, Middletown, NY 10940 845-341-2500 Inpatient addiction treatment center, 21 or 28 day treatment program. Fee: Sliding scale fee, Medicaid, some other insurances with qualifications. Riverside House Inc. Support Center 181 Rt. 209, Port Jervis, NY 12771 845-856-9005 Provides treatment for chemically dependent women and men. Some of their services include AIDS/HIV education and counseling, case management. Fee: Medicaid and other insurances. Orange County Community Health Assessment 2010-2013 Section III 20

NUTRITION: RECAP, Inc.- Nutrition Program 40 Smith Street, Middletown, NY 10940 845-342-3978, Ext. 30 Serves low-income families and individuals, Emergency food pantry, referrals to various agencies. Fee: None Orange County Dept. of Health WIC Program 33 Fulton Street, Middletown, NY 10940 845-346-1300 856 Route 17M, Monroe, NY 10950 845-201-2044 WIC is a supplementary food program for women, infants and children. WIC provides nutritional education and food vouchers to insure adequate nutrition. Fee: Income bases; pre-qualified through DSS. Meals On Wheels 50 East Main Street, Middletown, NY 10940 845-342-0088 20 Grand Street, Warwick, NY 10990 845-986-3389 35 Cerone Place, Newburgh, NY 12550 845-562-3490 Meals on Wheels is an organization that provides nutritious meals to people who are homebound and/or disabled or would otherwise be unable to maintain their dietary needs. Meals on Wheels seeks to provide the best quality food and nutrition for the least price to its clients. Fee: Based on how many meals are received during the week. Call for specific information. Cornell Cooperative Extension/Expanded Food & Nutrition Education Program (EFNEP) 1 Ashley Avenue, Middletown, NY 10940 845-344-1234 Web: www.cce.cornell.edu/orange EFNEP is a nutrition education program for low income families with young children throughout Orange County. One-on-one and group instruction is offered on how to improve diets using available resources. Bilingual staff available. Fee: None Cornell Cooperative Extension EAT SMART New York 1 Ashley Avenue, Middletown, NY 10940 845-344-1234 Web: www.cce.cornell.edu/orange EAT SMART New York targets food stamp participants and applicants throughout Orange County. Conducts group instruction on budgeting, meal planning, saving money on food purchases and easy, quick recipes. Bilingual staff available. Fee: None Orange County Community Health Assessment 2010-2013 Section III 21

FOOD PANTRIES: Florida Community Church Food Pantry 1 N. Main Street, P.O. Box 94, Florida, NY 10921 845-651-4117 Farm Workers CC Food Pantry P.O. Box 607, Pulaski Highway, Goshen NY 10924 845-651-4272 Highland Mills UM Church Food Pantry Rt. 32 & Ridge Road, Highland Mills, NY 10930 845-928-6177 St. Margaret's Soup Kitchen 12 Depot Street, Middletown, NY 10940 845-344-0569 Meals on Wheels of Middletown, Inc 50 East Main Street, Middletown, NY 10940 845-342-0088 Good Samaritan Pantry 80 West Main Street, Walden, NY 12586 845-778-2008 Methodist Church Pantry Rt. 208, Montgomery, NY 12549 845-778-7035 (*tried to verify ph #, no answer) St. Andrew's Church Food Pantry 15 Walnut Street, Walden, NY 12586 845-778-5310 Mid Hudson Christian Church 2393 Rt. 300, Wallkill, NY 12589 845-895-3006 First Presbyterian Church Food Pantry 30 Goshen Avenue, Washingtonville, NY 10996 845-496-3814 Path Stone (Food Pantry) *formerly Rural Opportunities 130 Dolson Avenue, Middletown, NY 10940 845-343-0771 Salvation Army Food Pantry 80 West Main Street, Middletown, NY 10940 845-343-0821 St. Paul's UM Church Food Pantry 58 West Main Street, Middletown, NY 10940 845-343-4425 *By appointment only. St. Patrick's Church Soup Kitchen 55 Grand Street, Newburgh, NY 12550 845-561-0885 Grace UM Church Food Pantry PO Box 2556, Newburgh, NY 12550 845-561-0176 New City Partners Outreach 65 Henry Avenue, Newburgh, NY 12550 845-565-4659 New Hope Baptist Church Food Pantry 20 Mill Street, Newburgh, NY 12550 845-562-0191 Salvation Army Food Pantry 234 Van Ness Street, Newburgh NY 12550 845-562-0413 Salvation Army Food Pantry 99 Ball Street, Port Jervis, NY 12771 856-4089 Warwick Methodist Church Food Pantry Forester Avenue, Warwick, NY 10990 845-986-1030 Orange County Community Health Assessment 2010-2013 Section III 22

HOME CARE SERVICES: Willcare 700 Cooperate Blvd., Newburgh, NY 12550 845-561-3655 Medicare and Medicaid certified to provide home care services to residents of Orange and Ulster counties. Services include skilled nursing (Pentam and Infusion services), physical, occupational and speech therapies, social work services and home health aides. Transportation provided through ARCS. Fees: Medicare, Medicaid, Other Insurances Homemaker Service of Orange County 70 Fulton Street, Middletown, NY 10940 845-343-0886 Personal care and home health aides assist with meal preparation, light housekeeping and personal care services. The Educational Homemaker program teaches families parenting and household management skills, helping to create a safe environment for children in the home. Fees: Medicare, Medicaid, Other Insurances Good Samaritan Hospital Home Care/Goshen Office 15 Matthews Avenue, Goshen, NY 10924 845-294-2011 Web: www.goodsamhosp.org/html/homecare.html Certified Home Health Agency (CHHA) specializing in Managed Long Term Care, AIDS Home Care Program (AHCP) and Long Term Home Health Care Program (LTHHCP). Fee: Medicare, Medicaid and Other Insurance. Wellness Home Care 252 Main Street, Goshen, NY 10924 845-294-8364 Web: www.wellnesshomecare.com Provides home health care for Infusion Nursing, Pediatrics, Wound Care, Ventilator Care and Diabetic Management. Fee: Medicaid and Most Insurance Accepted Any Time Home Care 53 Route 17K, Newburgh, NY 12550 845-565-1212 200 Midway Park Drive, Middletown, NY 10940 845-344-4222 Provides registered and licensed practical nurses, home health aids, personal care aides, physical, occupational and speech therapists and intravenous (IV) therapy. Fees: Medicare, Medicaid, Other Insurances Unlimited Care, Inc. 453 Route 211 East, Middletown, NY 10940 845-342-2220 Web: www.unlimitedcareinc.com Licensed agency providing personal care home health aides and live-in aides to assist clients with daily activities. Fees: Medicare, Medicaid, Other Insurances Elant Long Term Home Care 46 Harriman Drive, Goshen, NY 10924 845-291-3700 Web: www.elant.org Provides Adult Day Health Care, Adult Home Living, Child Care Services, Community Health Services, Personal Emergency Response System, Nursing Home Care, Rehabilitation and Retirement/Independent Living Services. Services may vary by office. Call for locations. Fee: Medicare, Medicaid and Other Insurance. J and D Ultracare Corporation 219 Quassaick Avenue, New Windsor, NY 12553 845-561-7051 Web: www.jdultracare.com/service.html Offers skilled nursing care to children whose condition and recovery will be better served in the familiar surroundings of their own homes. 24-hour-a-day, 7 day-a-week availability for skilled nursing care by pediatric nurses in Neonatal ICU, Pediatrics, IV Therapy, Neurology, Cardiology, Gastroenterology, Hospice Care, Maternal/Child Health and other Perinatal Specialties. Home visits by a pediatric supervisor to evaluate the care provided by our nursing staff. Fee: Call for information. Orange County Community Health Assessment 2010-2013 Section III 23

LEARNING INSTITUTIONS: SCHOOL DISTRICTS: Chester Union Free School District (845) 469-2231 3 Maple Ave. Chester, NY 10918 Cornwall School District (845) 534-8908 10 Dragon St, New Windsor, NY 12553 Florida Union Free School District (845) 651-3095 P.O. Box 757-51 N. Main St. Florida, NY 10921 Goshen Central School District (845) 294-2410 227 Main Street, Goshen, NY 10924 Greenwood Lake Union Free School (845) 477-7395 1247 Lakes Road, Greenwood Lake, NY 10925 Highland Falls Central School (845) 446-4738 P.O. 286, Highland Falls, NY 10928 Kiryas Joel Village School (845) 782-2300 Kahan Dr. Monroe, NY 10950 Marlboro Central School District (845) 236-5802 50 Cross Road, Marlboro, NY 12542 Middletown City School District (845) 341-5300 223 Wisner Avenue, Middletown, NY 10940 Minisink Valley Central School (845) 355-5110 Minisink Campus, Rt. 6, Box 217, Slate Hill, NY 10973 Orange/Ulster BOCES Gibson Road, Goshen, NY 10924 845-291-0100 Board of Cooperative Educational Services Special Education Training & Resource Ctr. 845-291-0520 Offers specialized education programs for its component school districts, including occupational education classes for high school students, special education classes for children with learning disabilities, and adult occupational education. All programs are operated in compliance with federal law prohibiting discrimination because of race, color, religion, sex, national origin, or handicapping conditions. Any student in a component school district is eligible for admission to any occupational program with application to be made through local guidance counselors. Mount Saint Mary s College Director of Admissions 330 Powell Avenue, Newburgh, NY 12550 845-561-0800 Ext. 185 A coeducational liberal arts college offering courses leading to degrees of Bachelor of Arts and Bachelor of Science. Monroe Woodbury Central School (845) 928-2321 295 Route 32, Central Valley, NY 10917 Newburgh Enlarged City School District (845) 563-3500 124 Grand Street, Box 711, Newburgh, NY 12550 Pine Bush Central School District (845) 744-2031 Route 302, Box 700, Pine Bush, NY 12566 Port Jervis City School District (845) 858-3175 9 Thompson Street, Port Jervis, NY 12711 Tuxedo Union Free School District (845) 351-4799 P.O. Box 2002, Tuxedo Park, NY 10987 Valley Central School District (845) 457-2400 944 Route 17K, Montgomery, NY 12549 Wallkill Central School District (845) 895-2140 P.O. Box 310, 13 Main Street, Wallkill, NY 12589 Warwick Valley Central School (845) 987-3000 Sandforville Road, PO Box 595, Warwick, NY 10990 Washingtonville Central School (845) 497-2200 54 West Main Street, Washingtonville, NY 10992 Orange County Community College 115 South Street, Middletown, NY 10940 845-344-6222 1 Washington Center, Newburgh, NY 12550 845-562-2454 Web: www.sunyorange.edu A public, coeducational, two-year community college offering associate degrees in both liberal arts/transfer and career/technical fields. The college has an open admissions policy requiring a H.S. Diploma or equivalent for admission to most programs. West Point Military Academy Director of Admissions U.S. Military Academy, West Point, NY 10996 845-938-4011 The West Point graduate is awarded a Bachelor of Science degree and commissioned as an officer in the US Army. Candidates must meet specific academic, physical and medical requirements and must also obtain a nomination from a Member of Congress. Orange County Community Health Assessment 2010-2013 Section III 24

LEARNING INSTITUTIONS (Continued): SUNY New Paltz/Empire State College 5058 Fulton Street, Middletown, NY 10940 SUNY New Paltz: 845-956-4249/ESC: 845-956-4110 Web: www.newpaltz.edu Web: www.esc.edu SUNY New Paltz offers courses in nursing for students who are already registered nurses going for their baccalaureate in Nursing. Also offers courses for certificates of advanced study for educational administration. ESC focuses on people who want to get a college degree who choose not to follow the conventional path. Credits are given for life, work, volunteer or military experience. Offers courses that go toward a baccalaureate, working independently or with a mentor. SPECIAL NEEDS: Action Towards Independence 130 Dolson Avenue, Suite 35, Middletown, NY 10940 845-343-4284 ATI is a non-profit, non-residential and consumercontrolled resource, referral and advocacy agency, serving individuals with disabilities. Fee: None. Educational Learning Experience 28 Ingrassia Road, Middletown, NY 10940 845-341-0700 Serves children 5 to 21 with multiple handicaps and mentally challenged who cannot be served by the public education system. Fee: None. McQuade Children s Services Box 4064, 623 Route 94, New Windsor, NY 12553 845-561-0436 Web: www.mcquade.org A therapeutic childcare organization providing emotional, social and educational services for special needs children and their families, ranging from residential treatment to group homes, emergency diagnostic assessment, special education and a variety of community based preventative programs. Services by referral only. Fees: Paid by referring agency- i.e. Department of Social Services, School Districts, Probation Departments, Family Courts. Independent Living, Inc. 5 Washington Terrace, Newburgh, NY 12550 845-565-1162, TTY 845-565-0337 Web: www.myindependentliving.org Serving persons of all ages having psychiatric, physical, cognitive and/or perceptual disabilities by providing: individual and systems advocacy, peer counseling, independent living skills training, self-help and services coordination. Bilingual services. Fee: None. Heritage Riding for the Handicapped RR#1, Box 99A, Goshen Road, Chester, NY 10918 845-496-3134 This program offers horseback riding for the physically and mentally challenged individuals. Fee: Registration fee required Stony Ford Community Residence 490 Stony Ford Road, Middletown, NY 10941 845-692-4787 Program offers a 24-hour supervised community residence with trained staff. Providing training and assistance to the developmentally disabled, in the activities of daily living. Fee: Medicaid, Medicare and third party insurance. Orange County Community Health Assessment 2010-2013 Section III 25

SPECIAL NEEDS (Continued): Crystal Run Village, Inc. 601 Stony Ford Road, Middletown, NY 10941 845-692-4444 Web: www.crvi.org Sixteen community homes located throughout Rockland, Orange and Sullivan Counties. Two residential campus programs, which provide services and care to dually diagnosed individuals and adults with developmental disabilities. Provides respite services to families who are taking care of a family member who has a disability. Fee: Medicaid, Medicare, third party insurance. Orange County AHRC Admin Office, 249 Broadway, Newburgh, NY 12550 845-561-0670 Web: www.orangeahrc.org Provides training, housing and employment for the developmentally disabled to become independent, productive members of the communities. Informs the public of our clients needs and potentials. Provides help to the families of our clients. Fee: None Footings, Inc. 440 Route 17M, Monroe, NY 10950 845-783-7505 E-mail: footings.org@juno.org Programs for people with developmental disabilities- I May Not Be Perfect, But Parts of Me are Excellent. Social group for pre-teens and young adolescents focusing on discovering what makes each person special and unique. Runs in 6-week cycles during the school year. Club Rec.-Academic support, social recreation, creative arts and sports program meeting daily after school. HCBS Waiver Service Coordination. Fee: Based on program. Call for information Hudson House 245 Broadway, Newburgh, NY 12550 845-565-8575/845-565-8576 Web: www.mhaorangeny.com/hudsonhouse.htm Email: hudsonhouse@frontiernet.net A club based on the Fountain House model which offers vocational services and an opportunity for social interaction to persons recovering from mental or emotional illness. The vocational program assists members in obtaining employment in the local community. The program assists members with the basic skills necessary to become employed, or stay employed. On the job training is provided by Hudson House coaches, who accompany members to job sites. The job coach is gradually phased out, but follow-up support is provided for the duration of the position. Members must be CSS eligible and may be referred by other agencies or institutions. Self- referrals are also welcome. Occupations, Inc 16-24 Union Street, Middletown, NY 10940 845-342-5428 Web: www.occupations.org Provides assistance in making informed choices about where individuals want to live, learn, work and socialize. Also provides assessment and development of skills and supports. Fee: Based on program. Call for information. Autism Society of America- Hudson Valley Chapter 70 Kukuk Lane, Kingston, NY 12401 845-336-2616 1-800-328-8476 Web: www.autism-society.org Promotes lifelong access and opportunity for all individuals within the autism spectrum, and their families, to be fully participating, included members of their community. Education, advocacy at state and federal levels, active public awareness and the promotion of research form the cornerstones of ASA's efforts to carry forth its mission. Fee: None. Orange County Community Health Assessment 2010-2013 Section III 26

SPECIAL NEEDS (Continued): Occupations, Inc. Work Centers 15 Fortune Road West, Middletown, NY 10940 845-692-4454 Ext. 142 Web: www.occupations.org Operates work centers in Middletown and New Windsor where individuals can develop skills, attitudes and behaviors essential for obtaining jobs in the community. Fee: No program fee. Possible transportation fee. Vocational Educational Services for Individuals with Disabilities 200 Midway Park Drive, Middletown, NY 10940 845-346-4260 VESID serves those who have a medically verified physical, emotional, or mental disability. Services include counseling, vocational rehabilitation, vocational assessment, job placement, information and referral. Fee: Free for most programs if eligible. Winslow Therapeutic Riding Unlimited 328 Route 17A, Warwick, NY 10990 845-986-6686 Web: www.winslow.org E-mail: winslow2@warwick.net Provides a full range of horseback riding therapy programs for children/adults with disabilities/special needs in a natural farm environment. Riders are encouraged to reach their highest levels of proficiency. Open Wellness classes are also available. Training and continuing education programs for professionals in the field of therapeutic riding are held regularly. Radio Vision 619 Route 17M, Middletown, NY 10940-4395 845-343-1131 Ext 244 Web: www.rcls.org/rclshq/radio/ Email: dan@rcls.org Office: Monday-Friday 8 a.m.-4 p.m. Radio Vision is a radio reading service for blind and print handicapped people in the lower Hudson Valley. Any person with visual or physical impairments, who cannot use ordinary print materials, is eligible for this free service. Fee: Free HOT LINES: Addiction Crisis Center 845-343-1443 Alcoholism & Drug Abuse Council/ADAC 845-294-9000 Alzheimer's Association -- National Office 1-800-272-3900 Web: www.alz.org 24-hour hotline for Alzheimer's and related dementia. AMBER Alert NYS Police 518-457-8678 American Cancer Society 1-800-ACS-2345 Web: www.cancer.org Information and support groups schedule. National Health Information Center 1-800-336-4797 Web: www.health.gov/nhic New York State Adult Domestic Violence Hotline 1-800-942-6906 English 1-800-942-6908 Spanish New York State Office of Advocate for Persons with Disabilities 1-800-522-4369 voice and TTY Spanish speakers available Web: www.advoc4disabled.state.ny.us New York State Register for Child Abuse and Maltreatment Office of Children & Family Services 1-800-342-3720 Spanish-speakers available Web: www.ocfs.state.ny.us/main/cps Orange County Community Health Assessment 2010-2013 Section III 27

HOT LINES (Continued): American Council of the Blind 1-800-424-8666 Web: www.acb.org American Kidney Fund 1-800-638-8299 www.akfinc.org Flu Hotline Orange County Health Department (845) 291-4300 New York State Health Department 1-800-808-1987 Growing Up Healthy Hotline 1-800-522-5006 HEAP Home Energy Assistance Program 1-800-342-3009 Web: www.otda.state.ny.us Immigration Hotline 1-800-232-0212 March of Dimes Birth Defects Foundation 1-888-MODIMES Web: www.modimes.org Medicare Hotline 1-800-633-4227 Web: www.medicare.gov New York State Senior Citizens Hotline 1-800-342-9871 Web: www.aging.state.ny.us Poison Control Center 1-800-222-1222 Web: www.lirpaic.org Mental Health Association Helpline 1-800-832-1200 National Suicide Hotline 1-800-784-2433 Rape Hotline 1-800-832-1200 Red Cross 1-800-REDCROSS 1-800-733-2767 1-800-257-7575 Spanish speaking Web: www.redcross.org Spina Bifida Association of America 1-800-621-3141 Web: www.sbaa.org Substance Abuse Hotline 1-800-cocaine National Center for Missing and Exploited Children 1-800-843-5678 1-800-THE-LOST Web: www.ncmec.org Mobile Mental Health Hotline 1-888-750-2266 New York State Smoker s Quitline 1-866-NYQUITS (1-866-697-8487) Web: www.nysmokefree.com Orange County Community Health Assessment 2010-2013 Section III 28

MISCELLANEOUS: Habitat for Humanity of Greater Newburgh, Inc. 745 Broadway, Newburgh, NY 12550 845-568-6035 Web: www.habitatnewburgh.org Partners with low and middle-income families to build affordable housing within the City of Newburgh, offers opportunities for volunteers to get involved with the community, and hopes to help in the restoration of Newburgh. Fee: None. Are You Okay? Program Monroe Police Department 104 Stage Road, Monroe, NY 10950 845-782-8644 This program is offered only to the residents of the Town or Village of Monroe. Once registered, a member of the police department will call the home every morning to insure the safety of the resident. If there is no answer, a police officer is dispatched to the home to check on the resident. Fee: Free to Town/Village of Monroe residents only. Weatherization Assistance Program 40 Smith Street, P.O. Box 886, Middletown, NY 10940 845-342-3978 Ext. 27 or 29 Web: www.recap.org/wprecap.htm The purpose of the Weatherization Program is to improve the health and welfare of low-income families by upgrading their dwellings to make them more energy efficient, safe, and comfortable. The RECAP Weatherization Program improves the energy efficiency of homes occupied by those eligible for services. Services provided include: side-wall insulation, attic insulation, repair or replacement of broken doors and windows, caulk and weather-strip where needed, energy efficient lighting, showerheads, aerators, smoke detectors, carbon monoxide detectors, heating system may also be cleaned and serviced, replacement of your inefficient refrigerator, repair or replacement of your inadequate electric hot water heater. Eligible participants must meet federal low-income criteria, and live in Orange County. Priority status is given to the disabled, the elderly, and families with children. Participants may either own or rent the dwellings for which they are requesting Weatherization services. Fee: Call for information. AIDS-Related Community Services (ARCS) 473 Broadway, Newburgh, NY 12550 845-562-5005 This agency is dedicated to provide HIV/AIDS services to people in New York s Hudson Valley region. Services include case management, client advocacy, emergency assistance, education, outreach, and prevention for adults, children, families and the general community. Orange County Community Health Assessment 2010-2013 Section III 29

Exhibit 3.2 ORANGE COUNTY DEPARTMENT OF HEALTH STAFF PARTICIPATION COMMITTEES/COALITIONS/COLLABORATIONS COMMUNITY HEALTH OUTREACH ABCD Health Advisory Board City of Newburgh Youth Bureau Prevention Policy Board - Community Accountability Board Diabetes Prevention Coalition Healthy Orange Team Hudson River Fish Advisory Board Latinos Unidos Link s Committee (Port Jervis Community Meeting) Middletown Cares Middletown RECAP (Head Start) Migrant Health Services Coalition Newburgh Adolescent Pregnancy Prevention Services Community Council Newburgh Healthy Families Advisory Board Newburgh Loaves and Fishes Newburgh National Night Out Newburgh Substance Abuse Action Team Newburgh Weed and Seed Office for the Aging Advisory Board Orange County Eating Disorders Coalition Orange County Men s Alternative Sentencing Program Orange County Parenting Coalition Orange County Perinatal Consortium Orange County POW'R Coalition Orange County Teen Pregnancy Prevention Coalition Orange County Youth Bureau Advisory Board Port Jervis Council of Community Agencies Port Jervis National Night Out POW R Against Tobacco (Steering Committee) POW R Cessation Advisory Board POW R To Be Tobacco Free Project Linus Project Re-Entry Task Force School Wellness Committees ECSDM, Goshen Central, NECSD, Pine Bush, Warwick Valley The Orange County Women's Enrichment Program Town of Crawford Focus on Youth Initiative Weed & Seed Orange County Community Health Assessment 2010-2013 Section III 30

NURSING DIVISION Adult Protective Services Advisory Committee Department of Social Services Advisory Committee Elant Advisory Committee (Newburgh) Hudson Valley CHHA/LTHHCP Providers LTHHCP Council Mid Hudson Adult Immunization Coalition New York State Office for Aging Advisory Committee Office for the Aging Advisory Committee OCCC Nursing Department Advisory Committee Professional Advisory Committee for Hospice of Orange and Sullivan County Utilization Review for Mental Health EARLY INTERVENTION ABCD Head Start Health Advisory Board Autism Advisory Council Downstate Early Child County Officials (DECCO) Kiryas Joel Head Start Advisory Board NYSAC Children with Special Health Care Needs Legislative Committee OCCC Early Childhood Advisory Board OCCC Occupational Therapy Assistant Program Community Advisory Board Parenting Coalition Perinatal Consortium Perinatal Regional Forum Port Jervis Community Agency Coalition Pregnancy Prevention Coalition of Health Orange RECAP Head Start Policy Advisory Board SAMSA Coordinating Council Teen Parenting Coalition ENVIRONMENTAL HEALTH Hudson Valley Water Works LEPC - Local Emergency Planning Committee Orange County Water Quality Coordinating Committee Orange County Citizen's Foundation Waste & Water Committee Wallkill River Watershed Conservation and Management Plan Orange County Community Health Assessment 2010-2013 Section III 31

ORANGE COUNTY COMMUNITY HEALTH ASSESSMENT 2010-2013 SECTION FOUR: LOCAL HEALTH PRIORITIES A. PRIORITY LOCAL HEALTH NEEDS Determination of Priority Health Needs The current focus of state, regional, and local health planning is to improve community health and mitigate health disparities through primary and secondary prevention efforts aligned with the NYS Prevention Agenda. Primary prevention efforts promote healthy personal behaviors and environments with the goal of preventing diseases. Secondary prevention focuses on the early detection and treatment of disease to enable a cure or better outcome. The Prevention Agenda for the Healthiest State established 10 statewide public health priorities for local health departments, health care providers, and community partners to use as a framework to assess local health needs. Local health departments and hospitals co-lead the process of need identification in their communities, in close partnership with other key stakeholders such as Community Health Centers, health providers, community agencies, CBOs/FBOs, and community members. The ultimate outcome of this process is the joint determination of 2-3 local health priorities, and continued collaboration to define and implement action steps to address these priorities. As a component of the community health assessment process, OCDOH strengthened partnerships with health care facilities, providers, community agencies and groups and integrated their guidance on community health needs. Staff from all OCDOH Divisions serve in leadership capacities on community advisory boards, coalitions, and task forces, and meet regularly with community leaders and groups to assess health and service delivery needs. The Department's weekly senior staff meetings provide an opportunity to involve all OCDOH Division Directors in ongoing community health assessment activities, including the identification of populations at risk and local health priorities. Several integrated strategies were used to facilitate and invite agency, health care provider, and community input in establishing local health priorities. The first strategy was ongoing communication with and consultation from the community collaborators listed in Section III, Exhibits 3.1 and 3.2. OCDOH representatives meet with these groups regularly to discuss community-based health initiatives and emerging health and service delivery needs. In addition, two versions of a regional survey of local health needs were developed collaboratively with representatives from all HVR counties with assistance from health researchers at New York Medical College School of Public Health. This was supported by the NYSDOH HEAL 9 grant funds awarded to the Hudson Valley Region Health Officers Network (HVRHON), with Rockland County Department of Health as the lead agency. The surveys were administered in the community and online via the County s website to solicit input on local health needs from a diversity of community-based health providers, community agencies, and residents. Public Health interns administered the survey throughout the county. (See Exhibits 4.1a-b for Regional Local Health Needs Surveys) Healthcare provider/community agency surveys were mailed to over 700 provider sites in the county. A total of 166 surveys were completed, yielding a response rate of approximately 24%. Categorically, surveys were completed by: 59% Medical Practices 8% Community Health Centers 10% Diagnostic and Treatment Centers 1% Dental Practices 5% Mental/Behavioral Health Centers 10% Community-Based Organizations 1% Correctional Health Services 5% Other The resident survey was made available in both English and Spanish. Resident surveys were administered in a variety of settings including: DMV offices, farmer s markets, libraries, churches, private physicians offices, community and migrant health centers, senior centers, college campuses, local blood drives, county departments, shopping malls and OCDOH clinics. County residents were also informed of the survey by an article in the local newspaper, the Times Herald Record, which referenced the county website for online surveys. A total of 764 health surveys were completed by county residents ages 18 and over; 58 % of these were online versions. Although not representative of the county population as a whole, the residents completing the survey resided in 49 distinct zip codes in the county. The majority (45%) of respondents were adults ages 35-54, 22% were young adults ages 18-34, and 11% were adults ages 65 and over. Ninety-one percent (91%) of respondents described their race as White; 7% Black/African American and 1% Asian. Hispanic/Latinos comprised 12% of survey respondents. Approximately 9% of county residents completing the survey were foreign-born. Orange County Community Health Assessment 2010-2013 Section IV 1

In January 2009, OCDOH began the process of selection of health priorities by convening a series of meetings with local hospital and community health center representatives serving the county. These representatives served as the core Prevention Agenda Workgroup. A series of planning meetings were used to: 1) review status of the CHA/CSP process, 2) discuss the Prevention Agenda priorities and regional survey initiatives underway, 3) discuss emerging service delivery needs and trends to inform the selection of local health priorities, and 4) present current demographic and health status findings related to each health priority area. Health indicators were reviewed using relative comparisons for prevalence, incidence and mortality rates among county, regional, and upstate populations as well as national and state health targets specified in Healthy People 2010 and in the NYS Prevention Agenda 2013. As part of the local health priority identification process, OCDOH and local hospital leads co-convened Health Town Meetings in each of the county s 4 health planning regions, to gain further input and insight of health needs at the community level. These meetings were hosted by the hospital or medical center based in each region. Town meetings included an overview of the CHA/CSP process, Prevention Agenda Priorities, and discussion of leading health indicators in each priority area. A series of Key Questions were used to frame the discussion of local health needs, facilitated by a chief executive from the primary CHC in reach region. Key Questions included the following: 1. What are the most significant barriers to accessing health services for the families and individuals you serve? 2. What specific types of health services for adults are lacking in the county? 3. What specific types of pediatric or adolescent health services are lacking in the county? 4. Which types of health services provided by your agency or organization have the longest waiting times for appointments? 5. Which chronic diseases should be priorities for expanded programs and services in the county? 6. What types of additional preventive health education services are needed in the county? 7. What types of additional health screening and early detection services are needed in the county? 8. What are the most effective ways to reduce health disparities in the population you serve? 9. What impact has the economic recession and rise in unemployment had on the population you serve? What are the effects on service delivery by your agency or organization? 10. What health services are you especially satisfied with in the county? The primary needs identified during these Health Town Meetings are presented in Section III: Problems and Issues in the Community. The surveys and Health Town Meetings attempted to capture as broad participation as possible and reflect the issues in the communities in the 4 geographic areas. (See Exhibit 4.2 CHA Community Health Town Meeting Regions). Despite slight differences in geographic emphasis, the primary concerns raised were highly consistent. This information as well as the analysis of mortality, morbidity and EBRFSS data formed the basis of selection of local health priorities. The Prevention Agenda Workgroup guided the determination of unmet health needs, local health priorities, and opportunities for action. Workgroup representatives have extensive experience in public health and health services delivery, including service to high risk populations in the county. (See Exhibit 4.3, Prevention Agenda Workgroup Membership Roster) The outcome of this collaborative process was to reach consensus on the following three local health priorities: Access to Quality Health Care Chronic Diseases Healthy Mothers, Healthy Babies, Healthy Children (& Healthy Families) Key Focus Areas for improvement identified for each Health Priority follow: Access to Quality Health Care: Care and service coordination; Resident knowledge/awareness of available programs, services, and eligibility for benefits; Literacy/health literacy levels in education and outreach materials, forms, and applications; Access to and availability of mental/behavioral health and substance abuse counseling and testing services, especially for children and adolescents; Access to/availability of sub-specialty care services, especially for children and adolescents in: psychiatry, neurology, pulmonology, & endocrinology; Most critical sub-specialty services for adults: endocrinology, neurology, cardiology, orthopedic, specialized dentistry (e.g., periodontal, oral surgery);. Availability of primary health care providers with holistic approach to prevention (e.g., weight management, smoking cessation, nutrition counseling) vs. episodic treatment; Availability of primary and specialty care providers representative of populations served; Expanded hours of service delivery; Poverty, un/underinsured, and undocumented status resulting in delayed access to care and reliance on emergent care and lack of compliance with medication regimens (latter especially in elderly); and Stigma/lack of acceptance of public insurance programs and FQHC services. Orange County Community Health Assessment 2010-2013 Section IV 2

Chronic Diseases and Cancer: Based on health status and demographic indicators and service delivery trends, the following were identified as focus areas for improvement in care and service coordination and primary and secondary prevention efforts: Asthma/COPD Cancer Cardiovascular Disease (Cerebrovascular Disease and Congestive Heart Failure) Diabetes (Type II) Mental Health/Depression Obesity & Smoking (as early risk factors for many chronic diseases) Maternal, Infant, Child and Family Health: Receipt of early prenatal care, especially in minorities & teens; Breastfeeding rates (incidence and duration); Teen pregnancy rates, especially in 3 cities; Rates of EBLL, especially in children under the age of 6 in Middletown & Newburgh; Injury prevention, especially in teens/young adults and the elderly; and Reliance on emergent care due to lack of insurance, underinsured with high co-pays and deductibles. An overarching concern expressed in the local health need surveys and Health Town Meetings was the need for improved awareness of and access to primary and specialty care services, especially for uninsured and underinsured persons. It became clear in the Health Town Meetings and Prevention Agenda Workgroup meetings, that insurance status greatly affected access, particularly to specialty care. Inadequate numbers of medical providers who accept Medicaid Managed Care also emerged as a concern. Even for those with insurance coverage, access was felt to be limited by the lack of providers offering evening and weekend hours. Many residents (and community providers) reported the need to travel out of county (to Rockland, New Jersey, Westchester or New York City) for specialty expertise, particularly for pediatric subspecialists such as psychiatry, pulmonology, neurology, and endocrinology. This was common to both insured and uninsured populations. Transportation was raised in many forums not only as a barrier to access for care but also to obtain healthy foods on a regular basis, particularly in urban areas with a lack of direct access to lower cost supermarkets. CHCs reported about one-third of clients do not have access to private transportation. Accomplishments Related to Priority Areas The majority of OCDOH Programs overviewed in Section II: Local Health Unit Capacity Profile address local health priorities. In addition, a number of the county s coalitions and task forces listed in Section III Exhibit 3.2 target the 3 selected priorities. Illustrative highlights of OCDOH collaborative community based initiatives are summarized below by health priority area. Access to Care Promotion of CHP/FHP/MMC and facilitating health care enrollment (CHCs, WIC initiatives) Since the introduction of Medicaid Managed Care, Child Health Plus and Family Health Plus, the Community Health Centers in the county work with residents to access eligibility for these and other coverage programs. Orange County Department of Health WIC programs, Orange County Department of Social Services and the Maternal and Infant Services Network (MISN) also inform and educate clients about available low cost services and insurance coverage plans for which they may be eligible, financial assistance to access care, and facilitate access to primary and specialty care services. In addition, the Community Health Centers and hospital/medical centers have health plan representatives onsite to provide information and assist eligible residents in enrollment for health insurance coverage. Initiatives to improve the availability of specialty care include the addition of specialty care clinics at Orange Regional Medical Center (ORMC) for Medicaid and un/underinsured patients. Community Health Centers also report hiring specialists to provide onsite services at CHC. Cardiac catheterization facilities have also opened at St. Luke's and the Horton Campus of ORMC. ORMC has filed a Certificate of Need for a neonatal intensive care unit to be housed in its new consolidated facility scheduled to open in 2011. Early Screening and Detection Services for uninsured/underinsured The YWCA is the facilitating agency for the NYSDOH grant, Women's Health Partnership in Orange County. This enables uninsured women to participate in mammography and cervical cancer screening in women ages 40 and over. As the uninsured population is fluid, this also encourages routine screening as a habit to continue whether or not they remain without insurance coverage. The YWCA also administers the NYSDOH colorectal cancer screening and prostate cancer education grant reaching vulnerable population groups in the county. Coordinated outreach, engagement, and education services targeted to migrant farm workers, immigrants, the uninsured and other special populations by the FQHCs serving the county and a diversity of OCDOH programs are critical to improving health care access and utilization by these high risk groups. The Orange County Department of Health Resource Guide for Health-Related Services (Exhibit 3.1) and County Youth Bureau s Children, Youth, and Family Services Directory described in Section III: Problems and Issues in the Community provide valuable Orange County Community Health Assessment 2010-2013 Section IV 3

information on programs and services for county residents. Chronic Disease As described in Section II: Local Health Unit Capacity Profile, Healthy Orange promotes health and wellness by joining with public, private, not-for-profit health care providers, local businesses, community and faith-based organizations, and educational institutions to foster behavior changes to promote health and reduce chronic disease. Using an integrated program structure and evidence based models, Healthy Orange includes a constellation of programs addressing three core areas: healthy eating, increased physical activity, and living a tobacco free lifestyle. These programs are supported through a combination of county and grant funding. County-funded Healthy Orange initiatives include: Healthy Orange DayCares Healthy Orange Worksite Wellness Healthy Orange Seniors Together Healthy Orange initiatives which are primarily grantfunded include: Fit Kids of the Hudson Valley; Eat Well Play Hard; Strategic Alliance for Health (Building a Healthy Nation); and Comprehensive Tobacco Prevention and Control Initiatives (Includes Tobacco Control, Tobacco Cessation, ATUPA, Reality Check, and Tobacco Free Schools Programs). In terms of Tobacco Prevention and Control initiatives, OCDOH follows the CDC guidelines of taking a multifactional approach to reduce exposure to tobacco smoke. Specifically, ATUPA and the CIAA follow NYS Public Health Laws which emphasize the importance of stopping sales to minors and reducing public exposure to second hand smoke. The Reality Check program encourages teens to become aware of the manipulation of advertising, films etc. and to spread the word to others that smoking is not "cool" and is harmful to health. Orange County dedicates significant support to prevention education, materials and free cessation programs available to all county residents. (Refer to Section II Local Health Unit Capacity Profile for further information on Healthy Orange). The Migrant Health Services Program is a collaborative service of OCDOH and the Hudson Valley Migrant Health Program of the Hudson River Community Health Center based in Pine Island focusing on prevention, early detection, and treatment for chronic and communicable diseases, as well as injury and substance abuse prevention. Maternal, Infant, Child and Family Health OCDOH WIC Program reaches nearly 7,500 low income pregnant and breastfeeding women and their infants and children ages 5 and under in locations throughout the county with vital nutrition and health guidance, breastfeeding promotion, and referrals for health and social services. The WIC Program provides linguistically and culturally responsive services throughout the county. The majority of the WIC population served at the Monroe site is Hasidim from the village of Kiryas Joel. Staff have become educated and responsive to these families traditions and beliefs. Health education and promotion materials are readily translated into Yiddish which has also become useful for other divisions serving the Hasidic population such as communicable disease. Community Health Worker Program (CHWP) conducts outreach education, referral, and case management activities for high risk pregnant women and their families in high risk areas in the cities of Newburgh, Middletown, and Port Jervis. The CHWP provides family-centered education and engages pregnant women in early and ongoing prenatal and primary health care. The program works closely with Prenatal Care Assistance Programs operated by 2 CHCs in the county - Hudson River Community Health and the Middletown Community Health Center. Accessible programs to promote abstinence/delay of early sexual activity continue to be a priority in light of teen pregnancy rates in the county, as does the availability of affordable and confidential family planning services. OCDOH collaborates with community programs reaching adolescents to improve adolescent decision making and communication skills, resistance to peer pressure, and knowledge of the risks associated with sexual activity. OCDOH works closely with providers of adolescent reproductive health education and care services (e.g., Community Health Centers and Planned Parenthood) to assure the availability of affordable family planning services to those in need. Initiatives to promote universal lead testing The routine lead testing of one and two year olds is now NYS Public Health Law. OCDOH Lead Safe Orange program staff conduct outreach throughout the year in the three cities, targeting high-risk neighborhoods and providing education to parents on why they should have their children routinely tested at these ages. In addition, all pediatric offices in the county are visited annually by a health educator and provided with relevant materials. In 2005, OCDOH was awarded a NYSDOH Healthy Neighborhoods Program grant to provide door-to-door health assessment, education, and referral for residents in high risk zip codes for elevated blood lead levels. The program presently concentrates its efforts in the 12550 zip code (city of Newburgh), and is applying for NYSDOH funding to expand services to the city of Middletown. The HUD Lead Based Paint Hazard Control and NYSDOH Primary Prevention grant-funded Programs have expanded the county s capacity to intensify and target outreach in areas of highest incidence and prevalence of EBLLs - the cities of Newburgh, Middletown, and Port Jervis, as described in Section II Local Health Unit Capacity Profile. Orange County Community Health Assessment 2010-2013 Section IV 4

Exhibit 4.1a ORANGE COUNTY DEPARTMENT OF HEALTH Edward A. Diana County Executive Jean M. Hudson, MD, MPH Commissioner of Health Hudson Valley Regional Consumer Survey First, we would like to ask you some general questions that tell us a little about you. 1. What county do you live in? (check only one) Dutchess Orange Putnam Rockland Sullivan Ulster Westchester Don t Know 2. What is your zip code? 3. What category best describes your race? White Black or African American Asian or Pacific Islander Native American Other (please tell us) 4. Are you Hispanic/Latino? Yes No 5. What is your country of birth? United States Other (please tell us) 6. What is your sex? Male Female 7. Are you currently employed? Yes, full-time Yes, part-time No 8. During the past 12 months, what was your total household income before taxes? Less than $24,999 $25,000 - $49,999 $50,000 - $74,999 $75,000 - $99,999 $100,000 or more Orange County Community Health Assessment 2010-2013 Section IV 5

9. What is your age? 18-24 years 25-34 35-44 45-54 55-64 65-74 75 years and older 10. How tall are you without shoes? Feet Inches or Centimeters 11. How much do you weigh? Pounds or Kilos 12. When grocery shopping, how often do you or does someone else in your household buy fresh fruits and/or vegetables? Always (skip to question 14) Frequently (skip to question 14) Sometimes (skip to question 14) Rarely Never 13. If rarely or never, what are the main reasons? (check all that apply) Too expensive Not available where I shop or in my community Too far to get to Poor quality I do not like fresh fruits and/or vegetables I do not cook or only eat out Other (please tell us) Now, we would like to ask a few questions about your health and habits. 14. Do you have insurance coverage for? Health Yes No Don t Know Dental Yes No Don t Know Prescription Drugs Yes No Don t Know Mental Health Yes No Don t Know Cancer Screening Yes No Don t Know Orange County Community Health Assessment 2010-2013 Section IV 6

15. If no, what is the main reason you do not have insurance? Health Dental Prescription Drug Mental Health Cancer Screening Employer Employer offers Cannot afford does not offer but too expensive to buy on my own 16. How long has it been since you visited a doctor for a routine physical exam or check-up? In the past year (skip to question 18) In the past 2 years In the past 5 years Five or more years ago Never Don t Know 17. If never or more than 2 years ago, what is the main reason(s) you did not have a routine physical exam or check-up? (check all that apply) Cannot afford Co-pay or deductible too high Insurance does not cover Too far to travel Did not have transportation Did not have the time Cannot find a doctor who speaks my language Health Care Provider said it was not needed Do not like going / Afraid to go Did not have childcare Other (please tell us) 18. In the past 12 months, did you have a routine dental check-up? Yes (skip to question 20) No 19. If no, what is the main reason(s) you did not have a routine dental check-up? (check all that apply) Cannot afford Co-pay or deductible too high Insurance does not cover Too far to travel Did not have transportation Orange County Community Health Assessment 2010-2013 Section IV 7

Did not have the time Cannot find a doctor who speaks my language Do not like going / Afraid to go Did not have childcare Other (please tell us) 20. In the past 12 months, how did you pay for medicine prescribed by your doctor? (check all that apply) Did not have any prescriptions to fill Insurance Insurance plus co-pay Out of pocket (paid on my own) Could not afford to fill the prescription 21. Do you have a child(ren) under the age of 18 years old? Yes No (skip to question 26) 22. In the past 12 months, did your children get a routine physical exam or checkup? Yes Only some No 23. In the past 12 months, did your children get a routine dental check-up? Yes Only some No 24. Do your children have health insurance coverage? Yes Only some No Don t Know 25. Are you aware of no or low cost health insurance programs available for your children (e.g., child health plus or Medicaid)? Yes No 26. In the past 12 months, have you or any member of your family, traveled outside your county to get health care services? Yes No (skip to question 30) 27. What service(s) did you leave your county for? (check all that apply) Primary Care Dental Ob/Gyn Family Planning Orange County Community Health Assessment 2010-2013 Section IV 8

Pediatric HIV/STD Mental Health Specialty Hospital Care Other (please tell us) 28. What is the main reason(s) for traveling outside of your county for these services? (check all that apply) To get better quality care The health care provider is closer to my home / work No health care provider in my county Other (please tell us) 29. Where did you go to get your health care service(s)? (check all that apply) New York City New Jersey Pennsylvania Connecticut Another county located in New York State Other (please tell us) 30. In the past year, have you been advised to lose weight by your health care provider? Yes No I have not seen a health care provider in the past year 31. How would you describe your weight? Underweight Normal weight Overweight Obese 32. Have you been told by a health care provider that you have diabetes? Yes No (skip to question 34) 33. When was the last time you saw any health care provider for diabetes related care? In the past 2 months In the past 6 months In the past year Two or more years ago Never Orange County Community Health Assessment 2010-2013 Section IV 9

34. Have you been told by a health care provider that you have heart disease? Yes No (skip to question 36) 35. When was the last time you saw any health care provider for heart related care? In the past year In the past 2 years In the past 5 years Five or more years ago Never 36. During the past 12 months, have you been tested for any Sexually Transmitted Disease (STD) or HIV? Yes No Don t know STD HIV 36a. If yes, where did you get tested? (check all that apply) Doctor s Office Health Clinic County Health Department Hospital Location outside my county STD HIV 36b. If no, what is the main reason(s) for not getting tested? (check all that apply) STD Not sexually active I do not think I am at-risk Did not have the time Cannot afford Cannot find a doctor who speaks my language Too far to travel Did not have transportation Do not like going / Afraid to go Did not have childcare Other (please tell us) HIV Orange County Community Health Assessment 2010-2013 Section IV 10

37. Do you know where to go in the County for? Diabetes Testing Yes No Blood Pressure Testing Yes No Cholesterol Testing Yes No Cancer Screening Yes No Nutrition Education Yes No Weight Loss Programs Yes No Mental Health Yes No Family Planning Services Yes No HIV Testing Yes No STD Testing Yes No 38. In the past 12 months, did you go for? Diabetes Testing Yes No Blood Pressure Testing Yes No Cholesterol Testing Yes No Cancer Screening Yes No Nutrition Education Yes No Weight Loss Programs Yes No Mental Health Yes No Family Planning Services Yes No HIV Testing Yes No STD Testing Yes No If you or your partner are currently pregnant or have been pregnant in the past 5 years, please answer the following questions. 39. What was the mother s age at the birth of her first child? Less than 15 years old 16-20 21-30 More than 30 years old 40. For the most recent pregnancy, did the mother have health insurance? Yes No Don t Know 41. For the most recent pregnancy, did the mother get prenatal care? Yes No Don t Know Orange County Community Health Assessment 2010-2013 Section IV 11

42. For the most recent pregnancy, when did the mother have her first prenatal visit? 1-3 months 4-6 months 7-9 months Did not get prenatal care If the mother had Medicaid or PCAP health insurance during any pregnancies in the past 5 years, please answer the following questions. 43. In the past 5 years, did the mother lose Medicaid or PCAP health insurance after the birth of her baby? Yes (go to question 44) No Don t Know 44. Did the mother reapply for Medicaid or get health insurance from another source? Yes No Don t Know Thank you for completing this survey. Your input is very much appreciated. Project funding received through a NYSDOH HEAL 9 grant supporting a seven county health department consortium. Orange County Community Health Assessment 2010-2013 Section IV 12

Exhibit 4.1b ORANGE COUNTY DEPARTMENT OF HEALTH Edward A. Diana Jean M. Hudson, MD, MPH County Executive Commissioner of Health Hudson Valley Regional Provider Survey 1a.) Please check the category that best describes your agency (Check all that apply): Medical Practice Mental Health Center Community Health Center Community-Based Organization Diagnostic and Treatment Center Correctional Health Services Dental Practice Hospital/Clinic Other (Please Specify): 1b.) How many service sites/locations does your agency have? In what counties are they located? 2.) What types of services does your site provide? (Check all that apply): Dental Care for Adults Family Planning Dental Care for Children/Adolescents Prenatal Care/PCAP Primary/Preventive Health Care for Adults WIC Primary/Preventive Care for Children/Adolescents Other (Please Specify): 3.) What are the most significant barriers impacting your ability to provide care to your patients? (Please select no more than 5 and rank them on a scale of 1-5 with 1 being the most significant and 5 the least significant.) Limited staffing resources Limited bi-lingual staff Inadequate insurance reimbursement Patient lack of trust Limited or lack of access to specialists High patient no-show rate Patient non-adherence to treatment Cultural competency issues Limited space and/or equipment Patient inability to afford prescription medications Other (Please Specify): 4.) What are the most significant barriers your patients face in accessing health care from you? (Please select no more than 5 and rank them on a scale of 1-5 with 1 being the most significant and 5 the least significant.) Inability to pay for services or medications Too far to travel Limited availability of specialists Afraid to go Lack the time to go to appointments Lack childcare Limited availability of bi-lingual clinicians Lack of transportation Hours of operation not convenient Other (Please Specify): 5.) Please select the top 5 chronic health problems/issues facing the patients you serve. (Please select no more than 5 and rank them on a scale of 1-5 with 1 being the most significant and 5 the least significant.) Diabetes Cancer Heart Disease Asthma Obesity COPD Other (Please Specify): Orange County Community Health Assessment 2010-2013 Section IV 13

6a.) What are the health-related priorities in your service area? (Check all that apply): Improving access for the uninsured/underinsured to: Medical Care Dental Care Substance Abuse/Mental Health Services Expanding services: Prenatal Care Family Planning/Reproductive Health Dental Services Adding additional services: Primary Care Please specify type(s) (e.g. pediatric, adolescent, adult, family): Medical/Dental Specialty (e.g. cardiologists, oncologists, gerontologists, periodontists) Please specify type(s): Substance Abuse/Mental Health Please specify type(s): Home health care services Increasing health care providers that are: Representative of racial or ethnic minorities Please specify which minorities: Fluent in Spanish / other languages prevalent in the area Please specify which languages: For special needs population (e.g. immigrants, persons with disabilities, migrant farm workers) Please specify populations in highest need: Committed to eliminating health care disparities Improving availability of: Medical/Dental providers participating in Medicaid Managed Care/Child Health Plus Health-related outreach, engagement and support services Please specify which services: Health education/risk reduction services Please specify type(s): (e.g. adolescent pregnancy/substance abuse prevention/pediatric asthma): Screening and early detection services for disease (e.g. breast and cervical cancer screening, HIV testing) Please specify type(s): Public transportation services to improve access to health care appointments Other (Please Specify): 6b.) Of all the priorities listed in 6a, what are the top 3 health related priorities in your service area? 1. 2. 3. 7. What are your facility/agency s plans for future expansion? Expand services Scale down services No plans Don t know/not sure Thank you for completing this survey. Orange County Community Health Assessment 2010-2013 Section IV 14

Exhibit 4.2 Community Health Assessment Regions For Health Town Meetings Minisink Wallkill Crawford Deerpark Mount Hope New Windsor Middletown 1 Hamptonburgh Cornwall 2 3 Wawayanda Port Jervis Blooming Goshen Grove Highlands Greenville Chester Montgomery Woodbury Town of Newburgh City of Newburgh Population in all Four Regions: 377,169 Based on 2007 Census Population Estimates Warwick 4 Monroe Tuxedo Orange County Community Health Assessment 2010-2013 Section IV 15

Exhibit 4.3 Orange County Prevention Agenda Workgroup Roster NAME AGENCY/ORGANIZATION TITLE Alan Bernstein, M.D. Greater Hudson Valley Family Health Care Chief Medical Officer Mary Bevan OCDOH OCDOH CHA Consultant Clare Brady Bon Secours Charity Health System VP of Mission/OC Facilities Robert Dietrich OCDOH Director of Community Health Outreach Karen Dietz Bon Secours Charity Health System VP of Business Development & Planning Jocelyn Dummett, M.D. Middletown Community Health Center Medical Director Barbara Demundo Bon Secours Charity Health System Outreach Director Christopher Dunleavy OCDOH Deputy Commissioner of Health Marilyn Ejercito OCDOH Director of Patient Services Christopher Ericson OCDOH Director of PH Emergency Response Barry Hawkins OC Department of Mental Health Chemical Dependency Services Director Jean Hudson, M.D. OCDOH Commissioner of Health Executive Director Public Rob Lee Orange Regional Medical Center Relations/Marketing Lucia Lee St. Luke s/cornwall Hospital Community Outreach Specialist Eileen McManus Hudson River Health Care Practice Management Specialist Orange County Radiation Uma B. Mishra, M.D. OC Advisory Board of Health Oncology Danielle Nordlund Greater Hudson Valley Family Health Care Grants Coordinator Matt Schleiffer OCDOH Director of Environmental Health Jean-Paul Vallet Orange Regional Medical Center Senior Planning Analyst Director of Early Intervention Sheila Warren OCDOH Services Mirta Zapata-Popoca Hudson River Health Care Unit Manager Orange County Community Health Assessment 2010-2013 Section IV 16

ORANGE COUNTY COMMUNITY HEALTH ASSESSMENT 2010-2013 SECTION FIVE: OPPORTUNITIES FOR ACTION Introduction In defining opportunities for action, the intent is to focus and mobilize cohesive community action in the health priority areas selected to improve health and reduce health disparities among Orange County residents. Improving community health requires coordinated and systemic efforts among all stakeholders: health care providers; community, state, local, and federal health and human service agencies; community and faith-based organizations and groups; policy makers; schools; businesses and the residents they serve. The leading health concerns in Orange County, as in the state and the nation, result from a number of interconnected factors, many of which can be controlled or modified. Harmful behaviors such as smoking, overeating, poor nutrition, lack of physical activity, substance abuse, and unsafe sexual practices have major impacts on individual health. Economic and language/cultural differences present barriers to access and utilization of medical care and preventive health services. Income, unemployment, educational attainment, inadequate housing, and lack of transportation are social factors which impact health or limit access to care. Uncontrollable factors, including inherited health conditions or increased susceptibility to disease, also significantly influence health. In spite of the favorable health status enjoyed by most Orange County residents, health disparities persist and are concentrated in the county s uninsured and low income population groups. Families and individuals who live in poverty or are uninsured are more likely to have poor health status. Poverty underlies many of the social factors that contribute to poor health. Differences for many health indicators are also apparent by gender, race/ethnicity, age, and geographic area of residence. This information can be used to determine subgroups in the population in need of further assessment, as well as guide the development of programs and services to meet identified health needs. Expanded joint planning and coordination of programs and services among health partners in the community can reduce health disparities and improve the health of all county residents. Effective strategies to improve community health involve collaboration between providers, health agencies, educators, and community-based organizations and groups, and the public they serve. In determining opportunities for action, creative coordination and sharing of expertise and resources among agencies and organizations results in the most cost-effective approach. The following listing of Opportunities for Action and Potential Action Steps by priority health area was established by the Prevention Agenda Workgroup, with input from Regional Health Town Meetings and Provider/Agency and Resident Surveys. This provides the framework for future development of a community health action plan, integrating evidence-based interventions, to build and sustain community capacity focused in the selected priority areas. The Prevention Agenda Workgroup will join together with the Healthy Orange Team, to accomplish the following: Coordinate and leverage resources for new initiatives; Develop innovative approaches and advance strategic health planning; Disseminate best practices and lessons learned; and Monitor and evaluate progress based on Prevention Agenda targets. Orange County Community Health Assessment 2010-2013 Section V 1

ACCESS TO CARE OPPORTUNITIES FOR ACTION Promote medical home/gatekeeper for all residents Expand outreach & facilitated enrollment services for public insurance programs at all points of care POTENTIAL ACTION STEPS IDENTIFIED How do community health partners accomplish through existing programs/services, collaboration, and new initiatives? Collaborate with MISN to increase opportunities for enrollment in Medicaid Managed Care (MMC), Child Health Plus (CHP), and Family Health Plus (FHP) through eligibility screening onsite in hospital, health care and community sites. Encourage development of low literacy level print materials in multiple languages with key information on FQHC services for distribution at diverse locations (e.g., hospitals, ERs, CHCs, group practices, CBOs, FBOs, OCDOH clinics, unemployment & DSS offices). Expand outreach to faith-based organizations and strengthen linkages with established Interfaith and Ecumenical Councils in high need communities. Encourage/support electronic medical record systems Promote efforts by hospitals and group medical practices to implement Electronic Medical Records Systems and secure funding support. Promote universal access to service & program information Recruit /retain specialty health/mental health providers in critical shortage areas/survey existing providers Advocate for restructuring of Medicaid reimbursement rates and reimbursement formulas Improve transportation services hours, frequency, and routes within and outside county Recruit/retain primary care providers and support staff who are representative of underserved populations at highest risk for health disparities Research and leverage funding support for a regional call center (e.g., Infoline 211). Intensify outreach to community leaders/cbos/fbos working with medically underserved populations regarding available programs & services, public insurance programs, and social services. Continue efforts to recruit outreach & engagement workers representative of communities of need. Explore partnerships to increase outreach capacity in high need areas, e.g., RSVP programs, college student health and social work internship programs. Continue participation in Children s Services County Systems of Care. Explore needs assessment to better define mental/behavioral health services shortages. Partner with Orange County Medical Society to develop recruitment plan for specialty providers. Support OCDSS efforts to inform state policy makers/elected officials of need to restructure reimbursement. Explore expansion of Orange County DSS Health Bus service to other areas. Develop linkages with Medical and Nursing Professional Societies; Medical, Nursing, and Allied Health Professional Colleges and Universities; and technical training programs. Improve availability of discounted Prescription services Partner with Orange County Office for Aging. Orange County Community Health Assessment 2010-2013 Section V 2

CHRONIC DISEASE OPPORTUNITIES FOR ACTION Research, pilot, and implement surveillance systems to better assess needs and target interventions (e.g., sentinel schools, health providers, Head Start/large Child Care Centers) Research, pilot, and replicate evidence-based models for prevention, early detection & treatment in chronic diseases of highest concern. (Regional approach) Enhance availability of communitybased screening/early detection programs & primary care and treatment services in high need areas. POTENTIAL ACTION STEPS IDENTIFIED How do community health partners accomplish through existing programs/services, collaboration, and new initiatives? Explore development of asthma surveillance system with school nurses in sentinel elementary schools and schoolbased health centers in high need districts. Develop linkages to recruit MPH and nursing interns to extend personnel resource capacity. Utilize School BMI surveillance data to target prevention and intervention programs. Assess the determinants of increased hospitalizations for asthma in children and adults and PQI chronic disease composites. Partner regionally through HVRHON/HEAL 9 Consortium to maximize outcomes and funding support. Collaborate with community partners to expand availability of evidence-based programs and services (in school, college, work and community settings) to reduce the prevalence of obesity in children, adolescents, and adults, emphasizing improvements in nutrition and activity patterns to achieve and maintain healthy weight throughout life. Work with food industry representatives to expand healthy food choices in school and work environments. Collaborate with community health providers to expand access to comprehensive CVD, cancer, asthma, and diabetes evidence-based prevention and intervention programs, including smoking cessation and nutrition counseling, especially for high risk minority and low income residents. Partner with Orange County/regional chapters of voluntary health agencies (e.g., American Lung Association, American Diabetes Association, American Heart Association, American Cancer Society) in planning and delivery of school and community-based prevention programs (i.e., asthma, diabetes, smoking prevention). Work with community partners to develop health messages that are responsive to the interests and needs of target groups, and provide messages in culturally, language, and media appropriate formats i.e., social media to reach adolescents with health messages. Improve availability of low literacy, language appropriate health promotion materials in community and provider settings. Investigate grant opportunities to expand access to breast, cervical, prostate, and colorectal screening, especially for high risk minority and low income residents. Convene countywide task force focused on priority health needs. Expand membership in Healthy Orange Team to coordinate, sustain and monitor initiatives targeted to priority health needs. Orange County Community Health Assessment 2010-2013 Section V 3

MATERNAL, INFANT, CHILD & FAMILY HEALTH OPPORTUNITIES FOR ACTION Intensify & focus community outreach & engagement services related to importance of early prenatal care in areas of high prevalence; investigate determinants of not accessing early care Expand WIC, CHC & Hospital breastfeeding promotion and support initiatives POTENTIAL ACTION STEPS IDENTIFIED How do community health partners accomplish through existing programs/services, collaboration, and new initiatives? Collaborate with and support MISN, WIC, and CHWP initiatives, strengthen partnerships with community and faith-based leaders. Intensify efforts with schools and Parent Organizations in high risk communities. Continue participation in the Orange County Perinatal Consortium to improve access to early prenatal care. Collaborate with MISN/Regional Lactation Consortium. Support & expand community and schoolbased pregnancy prevention education. Focus efforts in high risk areas. Support and collaborate with Lead Safe Orange to reduce incidence of EBLL in children < 6 years of age Partner with BOCES and community-based pregnancy prevention programs. Explore opportunities for parents to develop skills in discussing sexuality issues with their children. Collaborate with community health partners to expand family planning education and services for adolescents and adults at high risk of HIV/STD infection and substance abuse. Disseminate outreach and risk reduction materials widely in communities of need; strengthen outreach to medical providers. Improvements in techniques for safe and less costly housing remediation are needed, as well as grant funds/loans for low income home owners. Explore expansion of programs to educate and to certify trained lead remediation specialists with community partners. Intensify health professional and public education to promote universal lead testing, especially in areas of high incidence/prevalence for elevated blood lead levels. Support/expand injury prevention initiatives using evidence-based models Explore options for comprehensive assessment of injury data to assist in the identification of areas needing intervention. Collaborate with community partners to expand injury prevention and education activities and media campaigns for the elderly, particularly regarding fall prevention and home safety, and for adolescents and adults to prevent MVA injuries. Expand OCDOH Healthy Neighborhoods Program to other high risk areas in the county; use social media to reach adolescents with prevention messages. Orange County Community Health Assessment 2010-2013 Section V 4

ORANGE COUNTY COMMUNITY HEALTH ASSESSMENT 2010-2013 SECTION SIX: COMMUNITY REPORT CARD Introduction The County Health Indicator Profile and County Indicators for Tracking Public Health Priority Areas compiled by NYSDOH were determined to contain the most comprehensive and authoritative listing of the leading health indicators for the county. As such, we have adopted these two reports as the Community Report Card for Orange County. The most recent edition of the County Health Indicator Profile is for the years 2003-2007; Orange County Indicators for Tracking Public Health Priority Areas data include years 2001-2006. Updates to the County Health Profile will be available through the NYSDOH website at http://www.health.state.ny.us/statistics/chip/orange.htm. Updates to the County Indicators for Tracking Public Health Priority Areas will be available at: http://www.ny.health.gov/prevention/prevention_agenda/indicators/county/orange.htm. The Orange County Community Health Assessment was developed to be readily accessible to official, voluntary, and community agencies; health care facilities; health care providers; community groups; and the general public to assist in and facilitate local and countywide health-related planning. This document is being distributed in print form to a variety of agencies, and is available to the public on request. In addition, an electronic version of the 2010-2013 Orange County CHA will be posted on the county and health department websites, and its availability will be promoted through county newsletters and the local media. Orange County Community Health Assessment 2010-2013 Section VI 1

County Health Indicator Profiles (2003-2007) Profile of: Orange County SOCIO-DEMOGRAPHIC(1) 2007 2006 2005 2004 2003 # Rate # Rate # Rate # Rate # Rate Population 377,169 376,392 372,893 370,352 363,153 Unemployment 7,824 4.3 7,667 4.3 7,568 4.3 8,236 4.7 8,167 4.7 Percent in Poverty 38,184 10.5 41,257 11.3 37,594 10.5 37,244 10.2 38,027 10.5 Median Household Income (in 64,799 63,551 61,773 54,771 53,139 dollars) PERINATAL HEALTH(2) Pregnancies (All ages) 7,156 90.6 7,203 89.8 6,829 87.1 6,880 87.6 6,744 86.9 - Age 10-14 8 0.6 12 0.8 10 0.7 17 1.2 5 0.4 - Age 15-19 727 50.3 639 45.3 626 46.4 597 45.0 588 46.4 Births 5,333 14.1 5,433 14.4 5,165 13.9 5,206 14.1 5,133 14.1 Low Birthweight (Less than 2500 362 6.8 365 6.7 396 7.7 366 7.0 331 6.4 grams) Prenatal Care (1st Trimester) 2,923 64.4 3,125 68.5 3,072 68.7 3,399 71.5 3,230 67.7 Infant Deaths 38 7.1 20 3.7 31 6.0 34 6.5 32 6.2 Neonatal Deaths 23 4.3 13 2.4 21 4.1 28 5.4 18 3.5 Postneonatal Deaths 15 2.8 7 1.3 10 1.9 6 1.2 14 2.7 Spontaneous Fetal Deaths (20+ 18 3.4 17 3.1 10 1.9 19 3.6 26 5.0 wks) MORTALITY (Rates per 100,000 Population) Total Deaths 2,498 662.3 2,399 637.4 2,465 661.0 2,499 674.8 2,505 689.8 Lung Cancer (Total) 184 48.8 165 43.8 176 47.2 186 50.2 159 43.8 Lung Cancer (Male) 98 51.7 89 47.1 92 49.0 99 53.1 88 48.3 Lung Cancer (Female) 86 45.8 76 40.6 84 45.4 87 47.3 71 39.2 Breast Cancer (Female) 55 29.3 37 19.8 49 26.5 62 33.7 39 21.6 Cervical Cancer 8 4.3 3 1.6 8 4.3 4 2.2 7 3.9 Cerebrovasular Disease 107 28.4 116 30.8 123 33.0 127 34.3 121 33.3 Diseases of the Heart 725 192.2 676 179.6 675 181.0 706 190.6 759 209.0 Homicides 9 2.4 7 1.9 7 1.9 12 3.2 7 1.9 Suicides 35 9.3 17 4.5 23 6.2 28 7.6 14 3.9 Unintentional Injury 100 26.5 105 27.9 98 26.3 91 24.6 83 22.9 Motor Vehicle 39 10.3 39 10.4 48 12.9 44 11.9 43 11.8 Non-Motor Vehicle 61 16.2 66 17.5 50 13.4 47 12.7 40 11.0 AIDS 8 2.1 11 2.9 12 3.2 11 3.0 17 4.7 Cirrhosis (Liver) 32 8.5 26 6.9 25 6.7 29 7.8 29 8.0 HOSPITALIZATIONS (Rates Per 10,000 Population) Pediatric (0-4) - Asthma 76 29.0 120 46.7 116 45.5 136 53.6 158 65.3 - Gastroenteritis 98 37.4 139 54.0 124 48.7 102 40.2 128 52.9 - Otitis Media 7 2.7 4 1.6 2 0.8 9 3.5 17 7.0 Drug Related 1,045 27.7 1,155 30.7 1,135 30.4 1,008 27.2 980 27.0 Head Injury (5) 264 7.0 295 7.8 246 6.6 267 7.2 243 6.7 Orange County Community Health Assessment 2010-2013 Section VI 2

DISEASE MORBIDITY (3) 2007 2006 2005 2004 2003 # Rate # Rate # Rate # Rate # Rate AIDS Cases (4) 33 8.7 32 8.5 43 11.5 42 11.3 52 14.3 Early Syphilis 10 2.7 3 0.8 1 0.3 10 2.7 2 0.6 Chlamydia Incidence 716 189.8 605 160.7 683 183.2 580 156.6 495 136.3 TB Incidence 7 1.9 4 1.1 3 0.8 9 2.4 14 3.9 Ecoli O157 Incidence 6 1.6 1 0.3 0 0.0 4 1.1 4 1.1 Meningococcal Incidence 2 0.5 0 0.0 2 0.5 2 0.5 1 0.3 Pertussis Incidence 19 5.0 69 18.3 30 8.0 115 31.1 38 10.5 Lyme Disease Incidence 510 135.2 467 124.1 536 143.7 518 139.9 587 161.6 N/A - Not Available. (1) Census population estimates were used for all years. Unemployment data from U.S. Bureau of Labor and Statistics Unemployment Rate is per 100 persons in the labor force. Percent of population in poverty and median household income are estimates from the U.S. Census Bureau. (2) Total Pregnancy Rate is per 1,000 women 15-44; 10-14 and 15-19 rates are per 1,000 women in these age groups. The Birth Rate is live births per 1,000 population. The Low Birthweight and Early Prenatal Care Rates are per 100 births. Infant, Neonatal and Postneonatal Death Rates are per 1,000 births. (3) Rates in this section are per 100,000 population. (4) AIDS Cases include ICD-9 diagnosis (5) Head Injury Cases are presented by ICD-9 codes 800-801.9, 803-804.9, 850-854.1, 925. Source: New York State Department of Health Orange County Community Health Assessment 2010-2013 Section VI 3

Orange County Indicators For Tracking Public Health Priority Areas Indicator Prevention Agenda 2013 Objective ACCESS TO QUALITY HEALTH CARE % of adults with health care coverage 1 100% % of adults with regular health care provider 1 96% % of adults who have seen a dentist in the past year 1 83% Early stage cancer diagnosis 2 : US 85.5% (2006) 80% (2006) 70.3% (2006) NYS 86.5% (2006) 85.0% (2006) 71.8% (2006) Orange County 83.5% (2003) NA Breast 80% 63% 63% 60% Cervical 65% 53% 51% 53% Colorectal 50% % cigarette smoking in adolescents 3 (past month) TOBACCO USE 12% % cigarette smoking in adults 1 12% COPD hospitalizations among adults 18 + years 4 (per 10,000) Lung cancer incidence 2 (per 100,000) 31.0 40% (1996-2003) 23.0% (2005) 20.1% (2006) 23.0 (2004) 41% (2001-2005) 16.3% (2006) 18.2% (2006) 39.7 (2004-2006) 73.7% (2003) Male 62.0 * 85.3 * 80.8 * 91.9 * Female 41.0 * 54.2 * 53.8 * (2004) (2001-2005) HEALTHY MOTHERS/ HEALTHY BABIES/HEALTHY CHILDREN % early prenatal care (1 st trimester) 5 83.9% 74.9% 90% (2005) (2004-2006) % low birthweight 5 births (<2500 grams) 5% Infant mortality (per 1,000 live births) 6 4.5 Increase % of 2 year old children who receive recommended vaccines (4 DTaP, 3 polio, 1 MMR, 3 Hib, 3 HepB) 7 90% % of children with at least one lead screening by age 36 months 8 96% - Prevalence of tooth decay in 3 rd grade children 9 42% Pregnancy rate among females aged 15-17 years 10 (per 1,000) 28.0 PHYSICAL ACTIVITY/NUTRITION % of obese children by grade level: (BMI for age>95 th percentile) 2 4 Years (WIC) 11 (pre-school) 11.6% 8.2% (2005) 6.9 (2005) 80.5% (2006) 53.0% (2004) 44.4 (2002) 14.8% (2004) 8.3% (2004-2006) 5.8 (2004-2006) 82.4% (2006) 82.8% (NYS excl. NYC) (2004 birth cohort) 54.1% (2004) 36.7 (2004-2006) 15.2% (2004-2006) K 12 5% - - NA 2 5% - - NA 4 5% - - NA 7 5% - - NA 10 5% - - NA 40% (2001-2005) NA 24.3% (2003) 38.3 (2004-2006) 63.0 * (2001-2005) 69.6% (2004-2006) 7.1% (2004-2006) 5.4 (2004-2006) NA 86.7% (2004 birth cohort) 56.6% (2004) 25.6 (2004-2006) 13.9% (2004-2006) Indicator Prevention US NYS Orange Orange County Community Health Assessment 2010-2013 Section VI 4

% of adults who are obese (BMI>30) 1 15% % of adults engaged in some type of leisure time physical activity 1 Agenda 2013 Objective 25.1% (2006) 80% 77.4% (2006) % of adults eating 5 or more fruits or vegetables per day 1 33% 23.2% (2005) % of WIC mothers breastfeeding at 6 months 11 24.3% 50% (2005) UNINTENTIONAL INJURY Unintentional Injury mortality (per 100,000) 13 17.1 * 39.1 * (2005) Unintentional Injury hospitalizations (per 10,000) 14 44.5 * - Motor vehicle related mortality (per 100,000) 13 5.8 * 15.2 * (2005) Pedestrian injury hospitalizations (per 10,000) 15 1.5 * - Fall related hospitalizations age 65+ years (per 10,000) 15 155.0 - HEALTHY ENVIRONMENT Incidence of children <72 months with confirmed blood lead level >= 10 µg/dl (per 100 children tested) 14 0.0 - Asthma related hospitalizations (per 10,000) 16 22.9% (2006) 74.0% (2006) 27.4% (2007) 38.6% (2004-2006) 21.0 * (2004-2006) 64.7 * (2004-2006) 7.7 * (2004-2006) 1.9 * (2004-2006) 196.0 (2004-2006) 1.3 (2003-2005) (Rate for NYS Excluding NYC) Total 16.7 * 16.6 * 21.0 * 16.0 * Ages 0-17 years 17.3 22.6 (2003) Work related hospitalizations (per 10,000 employed persons aged 16+ years) 14 11.5 - Elevated blood lead levels (>25 µg/dl) per 100,000 employed 0.0 - persons age 16+ years 14 CHRONIC DISEASE Diabetes prevalence in adults 1 5.7% Diabetes short-term complication hospitalization rate (per 10,000) 17 7.5% (2006) 31.5 (2004-2006) 16.0 (2004-2006) 6.0 (2004-2006) 7.6% (2006) Age 6-17 years 2.3 2.9 3.0 3.3 Age 18+ years 3.9 Coronary heart disease hospitalizations (per 10,000) 14 48.0 - Congestive heart failure hospitalization rate per 10,000 (ages 18+ years) 17 33.0 5.5 (2004) 48.9 (2004) Cerebrovascular (Stroke) disease mortality (per 100,000) 13 24.0 * 46.6 * (2005) Reduce cancer mortality (per 100,000) 2 5.3 (2004-2006) 61.2 * (2004-2006) 46.3 (2004-2006) 30.5 * (2004-2006) County 21.4% (2003) 73.5% (2003) 25.2% (2003) 48.9% (2004-2006) 27.4 * (2004-2006) 71.9 * (2004-2006) 12.0 * (2004-2006) 0.9 * (2004-2006) 221.8 (2004-2006) 2.0 (2003-2005) 21.8 (2004-2006) 31.4 (2004-2006) 37.6 (2004-2006) 6.1% (2003) Breast (female) 21.3 * 24.4 * 25.5 * 26.6 * Cervical 2.0 * 2.4 * 2.6* 2.9 * Colorectal 13.7 * 18.0 * (2004) 19.1 * (2001-2005) 4.5 (2004-2006) 70.6 * (2004-2006) 40.8 (2004-2006) 38.4 * (2004-2006) 23.5 * (2001-2005) Indicator Prevention Agenda 2013 Objective US NYS Orange County Orange County Community Health Assessment 2010-2013 Section VI 5

INFECTIOUS DISEASE Newly diagnosed HIV case rate (per 100,000) 18 23.0 Gonorrhea case rate (per 100,000) 19 19.0 Tuberculosis case rate (per 100,000) 20 1.0 % of adults 65+ years with immunizations 1 18.5 (2006) 120.9 (2006) 4.4 (2007) 24.0 (2004-2006) 93.4 (2004-2006) 6.8 (2004-2006) 11.0 (2004-2006) 38.5 (2004-2006) 1.4~ (2004-2006) flu shot past year 90% 69.6% 64.7% 66.9% ever pneumonia 90% 66.9% (2006) COMMUNITY PREPAREDNESS % population living within jurisdiction with state-approved emergency preparedness plans 21 100% - MENTAL HEALTH/SUBSTANCE ABUSE Suicide mortality rate (per 100,000) 13 4.8 * 10.9 * (2005) % adults reporting 14 or more days with poor mental health in last month 1 7.8% % binge drinking past 30 days (5 + drinks in a row) in adults 1 13.4% Drug-related hospitalizations (per 10,000) 22 26.0 - Healthy People 2010 Goal utilized * Rate age-adjusted to the 2000 US population ~ Fewer than 20 events in the numerator; rate is unstable s Suppressed (percent could not be calculated, fewer than 3 cases per year) 10.1% (2002-2006) 15.4% (2006) 61.0% (2006) 100% (2007) 6.4 * (2004-2006) 10.4% (2003-2005) 15.8% (2006) 34.0 * (2004-2006) 60.4% (2003) 100% (2007) 6.1 * (2004-2006) 10.7% (2003) 12.8% (2003) 29.3 * (2004-2006) DATA SOURCES 1. NYS (statewide) and US Data Source: Centers for Disease Control, Behavioral Risk Factor Surveillance System, http://apps.nccd.cdc.gov/brfss/index.asp and http://www.cdc.gov/brfss/technical_infodata/surveydata/2006.htm, NYS (county level) Data Source: NYS Department of Health, Expanded Behavioral Risk Factor Surveillance System (Expanded BRFSS), http://www.health.state.ny.us/nysdoh/brfss/expanded/2003/index.htm. Note: the Expanded BRFSS survey 38 localities (including individual counties and county groupings. For a list of counties and county groupings, http://www.health.state.ny.us/nysdoh/brfss/expanded/2003/docs/rptstlocreg.pdf. 2. NYS (statewide and county level) Data Source: NYS Cancer Registry, http://www.health.state.ny.us/statistics/cancer/registry/, US Data Source: National Cancer Institute, SEER Fast Stats, http://seer.cancer.gov/data/ 3. NYS (statewide) Data Source: New York State Department of Health, Youth Tobacco Surveillance New York State 2006, http://www.health.state.ny.us/prevention/tobacco_control/youth_tobacco_survey.htm, US Data Source: Centers for Disease Control, Youth Risk Behavior Survey, http://www.cdc.gov/healthyyouth/yrbs/ 4. NYS (statewide and county level) Data Source: New York State Department of Health, Statewide Planning and Research System (SPARCS); US Data Source: AHRQ Quality Indicators, http://www.qualityindicators.ahrq.gov 5. NYS (statewide and county level) Data Source: NYS Department of Health - Vital Statistics, NYS Community Health Data Set, http://www.health.state.ny.us/statistics/chac/chds.htm, US Data Source: Centers for Disease Control, National Vital Statistics Reports, Volume 56, Number 6 Births: Final Data for 2005 http://www.cdc.gov/nchs/data/nvsr/nvsr56/nvsr56_06.pdf 6. NYS (statewide and county level) Data Source: NYS Department of Health - Vital Statistics, NYS Community Health Data Set, http://www.health.state.ny.us/statistics/chac/chds.htm, US Data Source: Centers for Disease Control, National Vital Statistics Reports, Volume 56, Number 10 Deaths: Final Data for 2005, http://www.cdc.gov/nchs/data/nvsr/nvsr56/nvsr56_10.pdf 7. NYS (statewide) and US Data Source: Centers for Disease Control, National Immunization Survey (NIS), http://www.cdc.gov/vaccines/stats-surv/nis/data/tables_2006.htm 8. NYS (statewide and county level) Data Source: NYS Department of Health, NYS Childhood Lead Program 9. NYS (statewide and county level) Data Source: NY State Oral Health Surveillance System, http://www.health.state.ny.us/prevention/dental/docs/child_oral_health_surveillance.pdf, US Data Source: Healthy People Data 2010, Oral Health, http://wonder.cdc.gov/data2010/focus.htm 10. NYS (statewide and county level) Data Source: NYS Department of Health - Vital Statistics, NYS Community Health Data Set, http://www.health.state.ny.us/statistics/chac/chds.htm, US Data Source: Centers for Disease Control, National Center for Health Statistics, Recent Trends in Teenage Pregnancy in the US, 1990 2002, http://www.cdc.gov/nchs/products/pubs/pubd/hestats/teenpr eg1990-2002/teenpreg1990-2002.htm Orange County Community Health Assessment 2010-2013 Section VI 6

11. NYS (statewide and county level) and US Data Source: NYS Department of Health, The Pediatric Nutrition Surveillance System, http://www.health.state.ny.us/statistics/prevention/nutrition/cacfp/pednss/index.htm 12. NYS (statewide and county level) Data Source: NYS Department of Health, Division of Chronic Disease Prevention and Adult Health, Program Data. 13. NYS (statewide and county level) Data Source: NYS Department of Health - Vital Statistics, NYS County Health Assessment Indicators, http://www.health.state.ny.us/statistics/chac/chai/, US Data Source: Centers for Disease Control, National Vital Statistics Reports, Volume 56, Number 10 Deaths: Final Data for 2005, http://www.cdc.gov/nchs/data/nvsr/nvsr56/nvsr56_10.pdf 14. NYS (statewide and county level) Data Source: NYS Department of Health, NYS County Health Assessment Indicators, http://www.health.state.ny.us/statistics/chac/chai/ 15. NYS (statewide and county level) Data Source: New York State Department of Health, Statewide Planning and Research System (SPARCS) 16. NYS (statewide and county level) Data Source: NYS Department of Health, NYS Asthma Surveillance Summary Report, http://www.health.state.ny.us/statistics/ny_asthma, US Data Source: National Hospital Discharge Survey 2005, http://www.cdc.gov/nchs/data/series/sr_13/sr13_165.pdf 17. NYS (statewide and county level) Data Source: New York Department of Health, State Planning and Research System (SPARCS); US Data Source: AHRQ Quality Indicators, http://www.qualityindicators.ahrq.gov 18. NYS (statewide and county level) Data Source: NYS Department of Health, NYS County Health Assessment Indicators, http://www.health.state.ny.us/statistics/chac/chai/, US Data Source: Centers for Disease Control, HIV/AIDS Surveillance, http://www.cdc.gov/hiv/topics/surveillance/resources/factsheets/us_media.pdf 19. NYS (statewide and county level) Data Source: New York Department of Health, Communicable Disease Annual Reports, http://www.health.state.ny.us/statistics/diseases/communicable/2006/, US Data Source: Centers for Disease Control, STD Surveillance, http://www.cdc.gov/std/stats/tables/table1.htm 20. NYS (statewide and county level) Data Source: NYS Department of Health, NYS County Health Assessment Indicators, http://www.health.state.ny.us/statistics/chac/chai/, US Data Source: Centers for Disease Control, MMWR Weekly, March 21, 2008, Trends in Tuberculosis United States 2007, http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5711a2 21. NYS (statewide and county level) Data Source: NYS Department of Health, Emergency Preparedness Program data 22. NYS (statewide and county level) Data Source: NYS Department of Health, NYS Community Health Data Set, http://www.health.state.ny.us/statistics/chac/chds.htm Orange County Community Health Assessment 2010-2013 Section VI 7