PLEASE answer a few questions about yourself and your household.
1. Are you: _____Female _____Male
2. Are you: _____Single
_____Divorced, separated or widowed
_____Married or living together
- Including yourself, how many of your household members are in the following age categories:
(Write the number of people for each category.)
_____birth to 5 years old
_____6-17
_____18-64
_____65 or older
5. Do you: _____rent your home _____own your home
6. How long have you lived in your current home? _____years _____months
7. How long have you lived in your community? _____years _____months
- Where did you live before moving to your community? ____________________City
____________________State ____________________Country
9. What size community did you live in before coming to your present community?
_____City smaller than (your community) _____City about the same size
_____City larger than (your community) _____Lived in a rural area
_____None (I was born here)
10. Why did you come to your present community? (You may check more than one answer.)
_____Born here _____Reputation favoring this as a place to live
_____Employment _____Desirable geographic location
_____Health reasons _____To live in a bigger city
_____Friends/relatives live here _____To live in a smaller city
_____Other______________________________________________________________
11. What was the last grade of school you completed? (Check one)
_____High school graduate or less
_____Some college (including AA degree)
_____College graduate
_____Post graduate education
_____Other (please specify) ________________________________________________
12. Which of the following categories best describes your ethnic background?
_____African American (Black)
_____Asian American or Pacific Islander
_____Hispanic (Latino)
_____Anglo (White, Non-Hispanic)
_____Other (please specify) _________________________________________________
13. What is the approximate total income of your household from all sources?
_____less than $20,000 _____$60,000 - $79,000
_____$20,000 - $39,000 _____$80,000 - $99,000
_____$40,000 - $59,000 _____$100,000 or more
If anyone in your household is employed, please answer the following questions:
14. Is your workplace in another community? _____Yes _____No
- What is the one-way distance between your home and workplace? _________miles
- On a typical day, how long does the trip to work take you? _________minutes
- What mode of transportation do you use? __________________________________________
- How many people live in your community now?
_____under 10,000 _____50,000-74,000
_____10,000 - 29,000 _____75,000-99,000
_____30,000 - 49,000 _____100,000 or more
18. Would you prefer that your community:
_____Become more populated _____Increase housing density
_____Become less populated _____Decrease housing density
_____Have more open space/parkland _____Have less open space/parkland
_____Stay the same as it is now
