Imagine a ladder with steps numbered from zero at the bottom to ten at the top. The top of the ladder represents the best possible life for you and the bottom of the ladder represents the worst possible life for you.

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* 1. Indicate where on the ladder you feel you personally stand right now.

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* 2. On which step do you think you will stand about five years from now?

Now imagine the top of the ladder represents the best possible financial situation for you, and the bottom of the ladder presents the worst possible financial situation for you.

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* 3. Please indicate where on the ladder you personally stand right now.

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* 4. On which step do you think you will stand about five years from now?

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* 5. In general, how would you rate your physical health?

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* 6. In general, how would you rate your mental health, including your mood and your ability to think?

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* 7. How often do you get the social and emotional support you need from the community?

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* 8. How strongly do you agree with this statement? "I lead a purposeful and meaningful life."

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* 9. How would you currently rate our community well-being in the Fox Cities?

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* 10. In five years from now, if we continue to do things the way we've always done them, what would you rate our community well-being to be?

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* 11. What do you think positively contributes most to our community well-being?

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* 12. What do you think hinders our community's potential well-being?

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* 13. In what community do you live?  (e.g., city, town, village)

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* 14. What is your race?

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* 15. What is your ethnicity?

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* 16. What is your age?

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* 17. What is your gender?

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* 18. Would you like to be kept up to date about Imagine Fox Cities?
*By your acknowledgment and the information shared below, you agree to receive periodic updates from Imagine Fox Cities.  We do not share or sell the information you provide with anyone.

Contact Information:

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* 19. Email

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* 20. Phone Number

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