Neighborhood Environmental Survey - Mail survey

Appendix C

Mail Survey & FAQ’s

(Main Mail Survey Data Collection)

COVER PLACEHOLDER

Paperwork Reduction Act Burden Statement: A federal agency may not conduct or sponsor, and a person is not required to respond to, nor shall a person be subject to a penalty for failure to comply with a collection of information subject to the requirements of the Paperwork Reduction Act unless that collection of information displays a currently valid OMB Control Number. The OMB Control Number for this information collection is 2120-XXXX. Public reporting for this collection of information is estimated to be approximately 5 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, completing and reviewing the collection of information. All responses to this collection of information are voluntary. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to Rebecca Cointin, AEE-100, 800 Independence Ave. SW, Washington, DC 20591, or by email at [email protected].

OMB #2120-XXXX

Exp. XX/XX/XXXX

START HERE:

This survey should be filled out by an adult household member living at this address.

Please use a blue or black pen if available.

These first questions ask about your household.

1. Is there more than one person age 18 or older living in this household?

Yes

No GO TO number 5 on the next page

2. Including yourself, how many people age 18 or older live in this household?

3. The adult with the next birthday should complete this questionnaire. This way, across all households, this survey will include responses from adults of all ages.

4. Please write the first name, nickname or initials of the adult with the next birthday. This is the person who should complete the questionnaire.

5. Thinking about the last 12 months or so, when you are here at home, how much does each of the following bother, disturb or annoy you?

	Not at all 	Slightly 	Moderately 	Very 	Extremely 
a. Noise from cars trucks or other road traffic
b. Smells or dirt from road traffic
c. Smoke, gas or bad smells from anything else
d. Litter or poorly kept up housing
e. Noise from aircraft
f. Your neighbors’ noise or other activities
g. Any other noises you hear when you are here at home
If this bothers or annoys you, what is the noise?
h. Undesirable business, institutional or industrial property
i. A lack of parks or green spaces
j. Inadequate public transportation
k. The amount of neighborhood crime
l. Poor city or county services
m. Any other problems that you notice when you are here at home
I f this bothers or annoys you, what is the problem?

6. Now considering how you feel about everything in your neighborhood, how would you rate your neighborhood as a place to live on a scale from 0 to 10 where 0 is worst and 10 is best?

Worst 0 	1 	2 	3 	4 	5 	6 	7 	8 	9 	Best 10 

These last questions are about you and your household.

7 In what year were you born?

Y Y Y Y

8. Are you male or female?

Male

Female

9. Are you Hispanic or Latino?

Yes

No

1

X

0. What is your race? One or more categories may be selected.

Mark one or more.

White

Black or African American

American Indian or Alaska Native

Asian

Native Hawaiian or Other Pacific Islander

11. Starting with yourself, please mark the sex, and write in the age and month of birth for each adult 18 years of age or older living at this address.

Sex

Age

Month Born

(01-12)

SELF

Male

Female

Adult 2

Male

Female

Adult 3

Male

Female

Adult 4

Male

Female

Adult 5

Male

Female

Thank you. Please return this form in the postage paid envelope provided or mail it to:

Neighborhood Environment Survey

Westat

1600 Research Blvd. Room ## ###

Rockville, MD 20850

Toll-free number for questions: ###-###-####

Commonly Asked Questions About

The Neighborhood Environment Survey

What is this study about?

This is a study about the environmental conditions in American neighborhoods. Some of the questions will ask about your attitudes and how you feel about the conditions in your neighborhood.

Who is the sponsor?

The study is sponsored by the United States Department of Transportation, a branch of the Federal Government. Since 1967, the U.S. Department of Transportation has been responsible for considering neighborhood environmental quality when planning, developing and revising transportation-related policies. You can learn more about the U.S. Department of Transportation by visiting www.dot.gov.

Am I required to complete this survey?

Participation is voluntary and there are no penalties for refusing to answer. However, your household was randomly selected for the study and cannot be replaced with another household. Your cooperation is extremely important to help ensure the completeness and accuracy of the study.

Who will use this information?

The U.S. Department of Transportation will use the information to update transportation-related policies that affect the environment in neighborhoods across the U. S.

Who can I call with questions?

Westat, a statistical social science firm, is collecting the data. If you would like further information, you can contact Westat at 1-XXX-XXX-XXXX

How was my household selected?

Households were selected at random from all residential addresses in neighborhoods like yours in the U.S. By selecting households randomly, we will be able to obtain scientific, accurate information about your neighborhood. It’s important to participate, so that we have an accurate picture of all communities.