Using the scale below, please indicate you answer to each of questions 1 - 8, by circling one of the following letter abbreviations:
VS = Very Satisfied
S = Satisfied
N = Neutral
D = Dissatisfied
VD = Very Dissatisfied
1. How satisfied are you with the overall quality of life in your community? VS S N D VD
2. Beyond the borders of your community, how satisfied are you with the
overall quality of life in your region? VS S N D VD
How satisfied are you with each of the following conditions of your community
3. . . .the physical environment? VS S N D VD
4. . . .crime conditions? VS S N D VD
5. . . .economic conditions? VS S N D VD
6. . . .education conditions? VS S N D VD
7. . . .health conditions? VS S N D VD
8. . . .the number of people? VS S N D VD
9. . . .the kind of people? VS S N D VD
10. I feel that my community is a diverse community. (Circle one answer.)
Strongly agree Agree Neutral Disagree Strongly disagree
11. In a community, having many diverse kinds of people is . . . (Check one answer)
_____a strong disadvantage
_____a disadvantage
_____neither a disadvantage nor an advantage
_____an advantage
_____a strong advantage
12. The following questions concern your neighborhood and your neighbors. First, please circle the picture below which best describes your relationship with your neighborhood.
Using the scale below, please indicate you answer to each of items 13 - 33, by circling one of the following letter abbreviations:
SA = Strongly Agree
A = Agree
N = Neutral
D = Disagree
SD = Strongly Disagree
13. I borrow things and exchange favors with my neighbors. SA A N D SD
14. Noise that my neighbors make is sometimes a big problem. SA A N D SD
15. I feel strongly attached to this neighborhood. SA A N D SD
16. I have little interaction with any of my neighbors. SA A N D SD
17. I know about the things that go on in my neighborhood. SA A N D SD
18. I am similar to most other people in my neighborhood. SA A N D SD
19. If I have a personal crisis, I have a neighbor I can talk to. SA A N D SD
20. I am often irritated with some of my neighbors. SA A N D SD
21. I typically stop and chat with many of my neighbors when I run into them. SA A N D SD
22. There is someone whom I consider a spokesperson for this neighborhood. SA A N D SD
23. If I had to move from this neighborhood now, I would be sorry to leave. SA A N D SD
24. I visit many of my neighbors now and then. SA A N D SD
25. In this neighborhood, I do not worry about safety. SA A N D SD
26. I know the names of most of my neighbors. SA A N D SD
27. I learn about issues important to the neighborhood from my neighbors. SA A N D SD
28. I feel strong ties with members of my neighborhood. SA A N D SD
29. I have made new friends by living in this neighborhood. SA A N D SD
30. I do not feel at home in this neighborhood. SA A N D SD
31. I know who the civic leaders in my neighborhood are. SA A N D SD
32. I strongly identify with my neighborhood. SA A N D SD
33. I follow local political and community issues closely. SA A N D SD
Using the scale below, please indicate you answer to each line of the next question, by circling one of the following letter abbreviations:
VS = Very Satisfied
S = Satisfied
N = Neutral
D = Dissatisfied
VD = Very Dissatisfied
DK = Don’t Know (too little information to judge)
34. How satisfied are you with each of the following aspects of life that are available to your community’s residents?
a. Public school system VS S N D VD DK
b. Public library system VS S N D VD DK
c. Public transportation system VS S N D VD DK
d. Religious services (churches, synagogues, etc) VS S N D VD DK
e. Health services (clinic, hospitals, family planning centers) VS S N D VD DK
f. Children’s sports VS S N D VD DK
g. Children’s services (scouts, teen center, etc) VS S N D VD DK
h. Adult sports VS S N D VD DK
i. Adult services (senior center, education classes) VS S N D VD DK
j. City public safety services VS S N D VD DK
k. City trash and recycling services VS S N D VD DK
l. City information services (local TV, radio, newsletters, etc) VS S N D VD DK
m. Local businesses, shops and restaurants VS S N D VD DK
n. Parks and green space (trails, street trees, etc) VS S N D VD DK
o. University/College activities and services VS S N D VD DK
p. City events and happenings (fairs, concerts, farmers markets, etc) VS S N D VD DK
q. Access to art, music and other cultural activities VS S N D VD DK
35. Thinking ahead to the year 2020, do you think the quality of life in your community then will be . . .
_____Much worse than it is now
_____Worse than it is now
_____Neither worse nor better; about the same as it is now
_____Better than it is now
_____Much better than it is now
Below is a list of various types of volunteer organizations. In the space beside each item, please write the number of organizations of that type that you or members of your household belong to. Indicate only organizations in your community or metropolitan region.
36. Type of organization Number that we are members of
religious ____________
educational or alumni ____________
civic, charitable, service ____________
commercial, business, professional ____________
athletic or recreational ____________
political ____________
37. In the past year, how many of these organizations did you or members of your household contribute time to? _________
38. In the past year, how many of these organizations did you or members of your household donate money to? _________
39. In the past year, please indicate approximately how many times you did each of the following things. (Write a number on each line.)
Wrote any elected official or newspaper _________
Phoned, faxed or emailed any elected official or newspaper _________
Attended city commission, council or school board meetings _________
On the next page is a map of [insert name of your community or area]. Please mark the following THREE THINGS on it, and show them as clearly as possible:
- Mark an X
at the approximate location of your home on the map.
- Draw a thick outline
around the area that you consider to be your neighborhood.
- Mark an S
at any area(s) within your community where you frequently go for grocery shopping.
