Skip to content
SAFEO Healthy Living Survey
*
1.
Please enter the address of the survey location. (555 Main Road New City, MD 55555)
(Required.)
*
2.
How many of your family members graduated college?
(Required.)
More than 5
2 - 5
1 or 2
None, but family members are currently in college
None
Do not know
*
3.
How would you characterize your family's wealth?
(Required.)
Upper Class
Middle Class
Low Income
Poor
Below Poverty
*
4.
How old are you?
(Required.)
18-25
26-35
36-55
56-65
66+
*
5.
How close do you live to a store that sells fresh fruits and vegetables?
(Required.)
Walking distance
Must take bus or car
Do not know
*
6.
When grocery shopping, do you know how to read the food package nutrition facts?
(Required.)
Yes
No
Somewhat
Need help understanding
7.
Are any of these food outlets near you?
7-11
Aldi’s
Giant
Highs
Royal Farms
Safeway
Shoprite
Target
Walmart
WAWA
Whole Foods
Other
*
8.
Does your family live near a community garden?
(Required.)
Yes
No
Do not know
*
9.
Do you, or members of your family know their Body Mass Index (BMI)?
(Required.)
Yes
No
Do not know
10.
The following programs/services are offered at the survey location:
Recreation, children
Recreation, teenagers
Recreation, adults
Nutrition classes/information
Senior activities
Financial classes/information
Health information/services
*
11.
Do you live near a sports and recreation center or private sports facility?
(Required.)
Yes
No
Onsite recreation where I live
Do not know
*
12.
How safe is your neighborhood?
(Required.)
Very Safe
Somewhat Safe
Not Very Safe
Very Unsafe
Do not know
*
13.
In general, is the neighborhood:
(Required.)
Getting safer
Getting more dangerous
Staying the same
Do not know
*
14.
Within a one block radius of this building, how many times have you seen, heard, or experienced criminal activity in the last three months?
(Required.)
None
1
2
3
4
5 or more times
15.
If you have seen criminal activity, what type(s)?
Domestic Violence
Drug dealing
Vandalism
Burglary (break-in)
Shoplifting
Mugging/assault
Shootings/Gun violence
Robbery (hold up)
Car theft/car break-in
Prostitution
Arson
Drug use
Graffiti
*
16.
Do you think gangs or crews are active in this neighborhood?
(Required.)
Yes
No
Do not know
*
17.
Is there graffiti on this block?
(Required.)
Yes
No
Do not know
*
18.
Are there sidewalks on this block?
(Required.)
Yes
No
Do not know
*
19.
Is there a bus stop on this block?
(Required.)
Yes
No
Do not know
*
20.
Is there a fire hydrant on this block?
(Required.)
Yes
No
Do not know
*
21.
Are there abandoned/boarded-up buildings on this block?
(Required.)
Yes
No
Do not know
*
22.
Is there an unsignalized cross-walk on this block? (painted cross-walk without a stop sign or signal)
(Required.)
Yes
No
Do not know
*
23.
Are there outdoor parks or recreation areas on this block?
(Required.)
Yes
No
Do not know
24.
What kinds of services/businesses would you like to see in this neighborhood, if any?
Coffee/internet café’s
Restaurants, sit down
Laundromats
Restaurants, fast food (carry-out/drive-through)
Convenience stores
Medical offices/services
Gas stations
Farmers markets, seasonal
Food/grocery stores
Banks, financial services
Entertainment (bowling, movies, performances)
Gyms
Library/bookstore
Current Progress,
0 of 24 answered
