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What is your gender?
 
Male
 
Female
 
 
 
What is your marital status?
 
Single (Never married)
 
Married
 
Domestic partnership
 
Widowed
 
Divorced
 
Separated
 
Don’t know
 
 
 
What is your age?
 
Younger than 18
 
18 - 24
 
25 - 34
 
35 - 44
 
45 - 54
 
55 - 64
 
65 or older
 
Prefer not to answer
 
 
 
What is the highest level of education you have achieved?
 
Less than high school degree
 
High school degree or equivalent (e.g. GED)
 
Some college but no degree
 
Associate degree (e.g. AA, AS)
 
Bachelor's degree (e.g. BA, AB, BS)
 
Master's degree (e.g. MA, MS, MBA)
 
Professional degree (e.g. MD, DDS, JD)
 
Doctorate degree (e.g. PhD)
 
 
 
Please describe your current residence:
 
Owned by you or someone in household with a mortgage or loan
 
Owned by you or someone in household free and clear (no mortgage or loan)
 
Rented
 
Occupied without payment of rent
 
 
 
How do you feel about living in your current community:
   
 
 
 
Rank the top five (5) most urgent needs of your community in order of importance. (Skip all categories that are not your top 5.)
 
 
 
 
 
 
 
 
 
 
 
Education Support (tutoring, college entry ACT/SAT, summer school, math/science/writing support programs)
 
 
 
 
 
 
Literacy
 
 
 
 
 
 
Retail/Commercial Business (full service grocery stores, hardware stores, clothing stores, gas stations, restaurants)
 
 
 
 
 
 
Job Development/Creation (active recruitment to locate businesses that create jobs)
 
 
Availability of affordable daycare centers
 
 
Quality of early childhood education
 
 
 
 
 
 
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Affordability of prescription drugs
 
 
 
 
 
 
Quality of teaching at schools
 
 
 
 
 
 
Safety at schools
 
 
 
 
 
 
Availability of employment opportunities for adults
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
What is your current employment status?
 
What is your current employment status? Working more than one job
 
Working full-time (one job)
 
Unemployed looking for work
 
Unemployed not looking for work
 
Retired
 
 
 
Rank the top five (5) most serious problems facing youth 13-17 years old in the community you live in order of importance. (Skip all categories that are not your top 5.)
 
Availability of affordable daycare centers
 
 
 
 
 
 
Quality of early childhood education
 
 
 
 
 
 
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Affordability of prescription drugs
 
 
 
 
 
 
Quality of teaching at schools
 
 
 
 
 
 
Safety at schools
 
 
 
 
 
 
Availability of employment opportunities for adults
 
 
 
 
 
 
Availability of adequate transportation
 
 
 
 
 
 
Availability of supervised afterschool youth activities (educational, cultural, recreational)
 
 
 
 
 
 
Availability of youth employment
 
 
 
 
 
 
Availability of business that officer shopping and services in the community
 
 
 
 
 
 
Availability of agencies providing services to Seniors
 
 
 
 
 
 
Availability of agencies providing services to Youth
 
 
 
 
 
 
Availability of public safety services
 
 
 
What is your primary means of transportation?
 
 
Bicycle
 
Bus
 
 
Carpool
 
Motorcycle
 
Personal Vehicle
 
None, Walk
 
 
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