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SAFEO Healthy Living Survey
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1.
Please enter the address of the survey location. (555 Main Road New City, MD 55555)
(Required.)
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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
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3.
How would you characterize your family's wealth?
(Required.)
Upper Class
Middle Class
Low Income
Poor
Below Poverty
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4.
How old are you?
(Required.)
18-25
26-35
36-55
56-65
66+
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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
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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
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8.
Does your family live near a community garden?
(Required.)
Yes
No
Do not know
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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
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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
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12.
How safe is your neighborhood?
(Required.)
Very Safe
Somewhat Safe
Not Very Safe
Very Unsafe
Do not know
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13.
In general, is the neighborhood:
(Required.)
Getting safer
Getting more dangerous
Staying the same
Do not know
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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)?
Robbery (hold up)
Vandalism
Drug dealing
Car theft/car break-in
Mugging/assault
Burglary (break-in)
Prostitution
Arson
Shootings/Gun violence
Graffiti
Shoplifting
Drug use
Domestic Violence
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16.
Do you think gangs or crews are active in this neighborhood?
(Required.)
Yes
No
Do not know
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17.
Is there graffiti on this block?
(Required.)
Yes
No
Do not know
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18.
Are there sidewalks on this block?
(Required.)
Yes
No
Do not know
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19.
Is there a bus stop on this block?
(Required.)
Yes
No
Do not know
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20.
Is there a fire hydrant on this block?
(Required.)
Yes
No
Do not know
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21.
Are there abandoned/boarded-up buildings on this block?
(Required.)
Yes
No
Do not know
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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?
Restaurants, sit down
Farmers markets, seasonal
Medical offices/services
Gyms
Food/grocery stores
Library/bookstore
Laundromats
Convenience stores
Gas stations
Restaurants, fast food (carry-out/drive-through)
Coffee/internet café’s
Entertainment (bowling, movies, performances)
Banks, financial services
Current Progress,
0 of 24 answered
