How long have you lived in this neighborhood? Years: + Months:
Race: Asian - African American - Hispanic - White - Multi-ethnic
Sex: Female - Male
Age: 18-25 - 26-35 - 36-45 - 46-55 - 56-65 - 65+
In your opinion, what are the 3 most pressing public safety issues in this neighborhood?
1.
2.
3.
How do you think we should deal with those public safety issues? 1. 2. 3.
How safe do you feel living in this neighborhood? Very Safe - Somewhat Safe - Not At All Safe Why?
Compared to 5 years ago, how do you rate the safety of this neighborhood? Better - Worse - About the Same - Not Sure/NA Why?
How do you feel walking in your neighborhood during the day? Very Safe - Somewhat Safe - Not At All Safe Why?
How do you feel walking in your neighborhood at night? Very Safe - Somewhat Safe - Not At All Safe Why?
Have you or someone in your household been a victim of crime? Yes - No Explain:
Will You participate in the Neighborhood Watch Program? Yes - No - Not Sure
Are you interested in learning more about a Security patrol? Yes - No - Not Sure
If interested, would you be willing to pay a small fee for the security patrol? Yes - No - Not Sure
If training is provided, would you be willing to participate in Public Safety Committee sponsored Activities, such as Resident Code Enforcement? Yes - No - Not Sure
Special needs/services?
Name: Phone: Address: City, ST ZIP E-mail:
May we share your contact information with the volunteer organizers of the security patrol? Yes - No
Other Comments: