Cognitive Testing

O ffice

of

J usti ce P ro g r a ms

Innovation • Partnership • Safer Neighborhoods

U.S. Department of Justice Survey of Neighborhood Safety

Cover Page Graphics TBD

If you have any questions or concerns about this survey mailing, please call the Survey of Neighborhood Safety
Helpline at 1-xxx-xxx-xxxx or send an email to [email protected]

Formatting Under Development
NOTICE – Title 42, Section 3732, United States Code, authorizes the Bureau of Justice Statistics,
Department of Justice, to collect information using this survey. Title 42, Sections 3789g and 3735,
United States Code, also requires us to keep all information about you and your household strictly
confidential. According to the Paperwork Reduction Act of 1995, no persons are required to respond
to a collection of information unless such collection displays a valid OMB number. The valid OMB
control number for this information collection is xxxx-xxxx. The time required to complete this
information collection is estimated to average 6 minutes per response, including the time to review
instructions, search existing data resources, to gather the data needed, and to complete and review
the information collection. Send comments regarding this burden estimate or any other aspect of
this data collection, including suggestions for reducing burden, to DOJ Clearance Officer (xxxx)
ADDRESS, Washington DC ZIP.

U.S. Department of Justice
Survey of Neighborhood Safety
INSTRUCTIONS
â Please use a black or blue pen to complete this form.
â Mark

to indicate your answer.

â If you want to change your answer, darken the box

and mark the correct answer.

START HERE

The following questions ask about your neighborhood.
By neighborhood, we mean the general area around
your house or the building you live in, where you might
do things such as shopping, going to the park, or
visiting with neighbors.
1. O
 n the whole, is this neighborhood a good place
to live?

Yes

No

2. H
 ow much of a problem is litter, broken glass or
trash on the sidewalks and streets?

Never a problem

Almost never a problem

Sometimes a problem

Almost always a problem

Always a problem

3. H
 ow much of a problem is crime in your
neighborhood?

Never a problem

Almost never a problem

Sometimes a problem

Almost always a problem

Always a problem

Please indicate whether you strongly agree, agree,
neither agree nor disagree, disagree, or strongly
disagree with each of the following statements.
4. People around here are willing to help their
neighbors.

Strongly Agree

Agree

Neither Agree nor Disagree

Disagree

Strongly Disagree

5. This is a close-knit neighborhood.

Strongly Agree

Agree

Neither Agree nor Disagree

Disagree

Strongly Disagree

6. People in this neighborhood can be trusted.

Strongly Agree

Agree

Neither Agree nor Disagree

Disagree

Strongly Disagree

57483

7. P
 eople in this neighborhood generally get along
with each other.

Strongly Agree

Agree

Neither Agree nor Disagree

Disagree

Strongly Disagree

8. P
 eople in this neighborhood share the same
values.

Strongly Agree

Agree

Neither Agree nor Disagree

Disagree

Strongly Disagree

9. T
 he police are doing a good job in dealing with
problems that really concern people in this
neighborhood.

Strongly Agree

10. The police do a good job in responding to
people in the neighborhood after they have
been victims of crime.

Strongly Agree

Agree

Neither Agree nor Disagree

Disagree

Strongly Disagree

11. When people in your neighborhood call 911,
does help arrive quickly?

Yes

No

Don’t Know

12. How long have you lived at this address?

1 year or less

1 to 5 years

5 or more years

Telephone Number

Agree

Neither Agree nor Disagree

Disagree

Strongly Disagree

13. What is the best phone number to use to
contact you? (This phone number will only be
used for the purpose of this research study.)

-

-

Thank you for completing this survey. Please return your form in the postage paid
envelope provided or mail to:

Mail
to:

Name
Address
City, State Zip

57483