Community Service

Eco-Survey Sheet

Hello, my name is ______________________________________________________.

I am with the __________________________________________________ 4-H  club.

May I take a few minutes of your time to interview you on your opinion of ____________________ in this area? Your responses will be kept confidential, and we will use these survey results in our project studying _____________________________________________________________________.

Where do you live? _____________________________________________________

Sex of person:  o Female    o Male

Survey location: ________________________________________________________

How old are you?
o Teens
o 20s
o 30s
o 40s
o 50s
o 60+

1. How important are _______________________________________________ to you?
o Very unimportant
o Unimportant
o Important
o Very important
o Neutral

2. How important are ____________________________________ issues compared with other issues in the ____________________________________ area?
o Very unimportant
o Unimportant
o Important
o Very important
o Neutral

3. In your opinion, what is the most important issue facing _________________________ right now?

Optional questions:

4. Have you ever visited a ________________________________________________ ?
o Yes   If so, how much time have you spent there? ________________________
o No

5. How would you react to the following statement?
All _____________________________ should be _____________________________.
o Strongly disagree
o Disagree
o Agree
o Strongly agree
o Neutral

Adapted with permission from SHARED SPACE: Our Common Earth – Ecology and Relationships (4-H 1497). 4-H Youth Development, Michigan State University Extension, 1991.

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Last Updated: October 31, 2009
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