Form 1 Community Awareness Survey

AmeriCorps Community Awareness Survey

Please verify the following information:

Your name:

Your email address:

Your telephone:

Organization name:

List any other names your organization may be known by:

Organization address:

1. How familiar are you with AmeriCorps?

 Not at all Familiar  Somewhat Familiar  Moderately Familiar  Extremely Familiar

2. Do you know if any AmeriCorps members are serving in your community?

 Yes  No

3. Please fill in the table below, the organizations in your community that you interact with and the key contact and their information:

Organizations Name	Organizations Address	Key Contact name/Role	Email Address	Telephone Number	Alternate Contact	Email Address	Telephone Number	Key Partner (Y/N)
Org 1
Org 2
Org 3
Org 4
Org 5
Org 6
Coalitions
Workgroups

4. May we use your name to recruit other respondents for the survey from your community?

 Yes  No

5. May we use the name of your organization to recruit other respondents for the survey from your community?

 Yes  No