NAME: AGE:

ADDRESS: SEX:

SURVEY FORM
Directions: Encircle the letter of your chosen answer.

8.15.How
Howwould
important
you is it for
rate youryou to have clean
overall 22.
1. Do youoften
How support local
do you initiatives
recycle itemsaimed at
such as
air in yourof
awareness community?
environmental issues? improving environmental
paper, plastic, and glass? conditions?
a) High
a) Very important a)a) Yes, actively
Always
b) Moderate
b) Somewhat important b)b) Yes,
Sometimes
passively
c) Low
c) Not important c)
c) No Never
9. How often do you read or watch news 2. Do you use reusable bags when shopping?
16.related
How concerned are you issues?
to environmental about the quality 23. Howa)oftenAlways
do you educate others about
of drinking water in your area?
a) Frequently b) Sometimes
environmental issues?
a) Occasionally
b) Very concerned a)c) Frequently
Never
b) Rarely
c) Somewhat concerned 3. How b) often do you participate in community
Occasionally
c) Not
10. Do you believe that individual actions can
concerned c) Never
clean-up events?
significantly impact the environment? a) Frequently
17. Doa)youYes
use a water filtration system at 24. Howb)likely are you to participate in
Occasionally
home?
b) Somewhat environmental
c) Never advocacy or activism?
a) No
c) Yes a) Very likely
11. Howb)knowledgeable
Sometimes are you about climate b) concerned
4. How Somewhat likely
are you about air pollution in
c) No
change? c) area?
your Not likely
18. Have
a) you
Veryever tested your water for
knowledgeable a) Very concerned
contaminants?
b) Somewhat knowledgeable 25. Whatb)is Somewhat
your primary source of information
concerned
a) Not
c) Yesknowledgeable aboutc)environmental
Not concernedissues?
12. Howb)important
No, but Ido
plan to think it is to protect
you a) you
5. Have Newsnoticed
media any changes in air quality
localc)wildlife
No, andand
I don’t plan to
habitats? b) the
over Social
pastmedia
few years?
19. Howa) often
Very do you think about the impact
important c)a) Friends and family
Significant improvement
of pollution on local
b) Somewhat water bodies?
important b) No change
a) Not
c) Frequently
important c) Significant decline
13. Howb)doOccasionally
you typically dispose of your 6. How often do you check air quality reports?
c) Rarely
household waste? a) Regularly
20. Howa) important is it for you to have access
Regular trash b) Occasionally
to clean water?
b) Recycling c) Never
c)a) Composting
Very important 7. Do you believe that local industries contribute
14. Are b)
youSomewhat
aware of important
your local recycling to air pollution?
c) Not
guidelines? important a) Yes, significantly
21. Howa) often do you
Yes, very choose environmentally
aware b) Somewhat
friendly products?
b) Somewhat aware c) No
c)a) Not
Always
aware
b) Sometimes
c) Never