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Your Voice Matters! Community Survey! Think Outside the Box!
Help us envision the Proposed Burlington History & Culture Center.
OK
1.
Where was your best museum / historical site experience?
2.
Tell us what part of Burlington's history most interests you. Please include any ideas you have in the following areas:
Content Areas
(like Burlington's music history or the circus history):
Historical Themes
(like in trends in labor patterns):
Specific People
(like Madeleine Kunin or Richard Kemp):
3.
What museum features would be important to you in a Burlington History & Culture Center (like a kitchen, performance / educational spaces, sculptures)?
4.
Demographic Questions
(optional)
Please tell us what
AGE
RANGE
you fall in:
11 or under
12 - 19
20-39
40-59
60-79
80 and above
5.
What is the gender that you identify with:
6.
If you feel comfortable doing so please relate your sexual orientation:
7.
If you live in Burlington, please indicate which WARD your home is located within:
1
2
3
4
5
6
7
8
8.
Please describe your racial and ethnic identity (please check all that apply):
American Indian or Native Alaskan
Asian
Black (from the Americas)
Black (from outside the Americas)
Hispanic or Latino/a
Middle Eastern
Native Hawaiian or Pacific Islander
White
My race and/or ethnicity is not reflected in the above choices (please specify):
9.
If you selected American Indian or Native Alaskan, please provide some additional information (check all that apply):
Abenaki
Wampanog
Mohican
Mohegon
Mi'kmaq
Penobscot
Pequot
Mohawk
Cayuga
Tuscarora
Inuit
Mayan
Other (please specify)
10.
If you selected Asian, please provide additional information (check all that apply):
Chinese
Indian
Filipino
Vietnamese
Korean
Pakistani
Cambodian
Nepalese
Bhutanese
Thai
Other (please specify)
11.
If you selected Black (from the Americas), please provide additional information (check all that apply):
African American
Barbadian
Jamaican
Haitian
Other (please specify)
12.
If you selected Black (from outside the Americas), please provide additional information (check all that apply):
Nigerian
Ethiopian
Somali
Congolese
Moroccan
Ghanian
Other (please specify)
13.
If you selected Hispanic or Latino/a, please provide additional information (check all that apply):
Mexican
Puerto Rican
Salvadoran
Cuban
Dominican
Guatemalan
Colombian
Ecuadorian
Spanish
Peruvian
Other (please specify)
14.
If you selected Middle Eastern, please provide some additional information (check all that apply):
Lebanese
Pashtuns
Iranian
Palestinian
Syrian
Iraqi
Israeli
Jordanian
Other (please specify)
15.
If you selected Native Hawaiian or Pacific Islander, please provide additional information (check all that apply):
Samoan
Tongan
Fijian
Marshallese
Other (please specify)
16.
If you selected White, please provide additional information (check all that apply):
German
Italian
Irish
Polish
English
Scottish
French Canadian
Norwegian
Greek
Russian
Hungarian
Other (please specify)
Current Progress,
0 of 16 answered
