Community Member Survey
Community Member Survey
Please answer the following survey the best of your ability:
First, we would like to obtain some basic background information.
1) What is your
age?
___________________
2) What is your
gender?
___________________
3) Please describe your
ethniticity.
___________________
4) Can you describe your employment
status?
___________________
5) What is (are) your
occupation(s)?
___________________
___________________
6) How long have you worked at your
job?
___________________
7) How do you commute to
work?
___________________
8) Please state your yearly income range (in dollar
amount).__________________
9) How many people live in your
household?
___________________
10) Can you describe your household characteristics
(eg. Single family, couple, extended family,
etc.)
___________________
11) Please describe your education
level.
___________________
12) Do you have health insurance?
13) Are you a registered
voter?
___________________
14) How many vehicles do you own?
1) Of the following regions, which do you most identify as your
home?
____ Neighborhood ____ Town or Community ____ State ____ Greater Region
The following questions or statements are about personal and public
investments in your home, community, and lifestyle.
2) To what extent do the things that you own or rent (eg. home, car,
furniture, clothes, etc.) contribute to your quality of life?
____Poor ____Below Average ____Average ____Good ____Very High
3) To what extent do the public things in your community
(streets, sidewalks, streetlights, parking, etc.) contribute to your
quality of life?
____Poor ____Below Average ____Average ____Good ____Very High
4) To what extent do private investments (eg. shops, restaurants,
offices, etc.) in your community contribute to your quality of life?
____Poor ____Below Average ____Average ____Good ____Very High
4) The public (eg. parks, and community centers) and private spaces
(eg. businesses, and offices,) in my community are balanced.
____Definitely not true ____Not true ____Neutral ____ True ____Very true
The next questions or statements are about personal well-being and
investments made in yourself.
6) My personal income and the goods and services I purchase contribute
to my
Quality of life.
____Definitely not true ____Not true
____Neutral ____ True ____Very true
7) To what extent do investments made in yourself or personal growth
(eg. education, job skills, health, spirituality, etc.) contribute to
your quality of life.
____Poor ____Below Average ____Average ____Good ____Very High
8) My community supports my individual development and growth.
____Definitely not true ____Not true ____Neutral ____ True ____Very true
a. The opportunities for local employment are:
____Poor ____Below Average ____Average ____Good ____Very High
b. The support for human health in the community are:
____Poor ____Below Average ____Average ____Good ____Very High
c. The educational opportunities in the community are:
____Poor ____Below Average ____Average ____Good ____Very High
These questions or statements are about your relationships with family
and people in your community.
9) To what extent do relationships with your family and friends
contribute to your quality of life?
____Poor ____Below Average ____Average ____Good ____Very High
10) To what extent do interactions with people in your
neighborhood or community
contribute to your quality of life?
____Poor ____Below Average ____Average ____Good ____Very High
11) To what extent do the ownership provisions (structures or
agreements of property ownership) in your community affect your quality
of life?
____Poor ____Below Average ____Average ____Good ____Very High
12) The process for allocating work and rewarding contributions
in my community is:
____Poor ____Below Average ____Average ____Good ____Very High
13) The overall social interactions in my community are:
____Poor ____Below Average ____Average ____Good ____Very High
14) My community welcomes outsiders.
____Definitely not true ____Not true ____Neutral ____ True
____Very true
The following questions or statements are about access to, investments
in, and use of natural areas in or near your community.
15) To what extent does interaction with natural areas (open
space) in or near your community contribute to your quality of life?
____Poor ____Below Average ____Average ____Good ____Very High
16) My community’s efforts to preserve natural or “wild” areas,
ecosystems, and their benefits are:
____Poor ____Below Average ____Average ____Good ____Very High
17) How would you rate the list of following assets in your
community toward
contributing to your quality of life?
From 6 (most important) to 1 (least important)
____ Air Quality ____Water Resources____ Public open space
____Noise in your Neighborhood ____General Cleanliness ____ Other:
Lastly there are some questions or statements about your overall
quality of life.
17) The overall quality of life in my
community is:
____Poor ____Below Average ____Average
____Good ____Very High
18) My overall quality of life is:
____Poor ____Below Average ____Average
____Good ____Very High
19) Members of my community share common visions, and believe
similar
fundamental goals are important.
____Definitely not true ____Not true ____Neutral ____ True ____Very true
20) Please distribute 100 points across the following categories
according to how you
spend your working hours during a typical week.
____Employment ____Volunteer Work (formal and informal)
____Household Chores ____Family activities and entertainment
____Personal activities and entertainment ____ Other: (please describe)
21) Please distribute 100 points across the
following regions according to which ones
affect your quality of life.
____Neighborhood ____Town or community ____State ____Greater region