Imagine Fox Cities Well-Being Survey
Imagine a ladder with steps numbered from zero at the bottom to ten at the top. The top of the ladder represents the
best possible life for you
and the bottom of the ladder represents the
worst possible life for you
.
*
1.
Indicate where on the ladder you feel you personally stand right now.
(Required.)
Worst Possible
1
2
3
4
5
6
7
8
9
Best Possible
Worst Possible
1
2
3
4
5
6
7
8
9
Best Possible
*
2.
On which step do you think you will stand about five years from now?
(Required.)
Worst Possible
1
2
3
4
5
6
7
8
9
Best possible
Worst Possible
1
2
3
4
5
6
7
8
9
Best possible
Now imagine the top of the ladder represents the
best possible financial situation
for you, and the bottom of the ladder presents the
worst possible financial situation
for you.
*
3.
Please indicate where on the ladder you personally stand right now.
(Required.)
Worst Possible
1
2
3
4
5
6
7
8
9
Best Possible
Worst Possible
1
2
3
4
5
6
7
8
9
Best Possible
*
4.
On which step do you think you will stand about five years from now?
(Required.)
Worst Possible
1
2
3
4
5
6
7
8
9
Best Possible
Worst Possible
1
2
3
4
5
6
7
8
9
Best Possible
*
5.
In general, how would you rate your physical health?
(Required.)
Excellent
Very Good
Good
Fair
Poor
Excellent
Very Good
Good
Fair
Poor
*
6.
In general, how would you rate your mental health, including your mood and your ability to think?
(Required.)
Excellent
Very Good
Good
Fair
Poor
Excellent
Very Good
Good
Fair
Poor
*
7.
How often do you get the social and emotional support you need from the community?
(Required.)
Always
Usually
Sometimes
Rarely
Never
*
8.
How strongly do you agree with this statement? "I lead a purposeful and meaningful life."
(Required.)
Strongly Agree
Agree
Neutral
Disagree
Strongly Disagree
Strongly Agree
Agree
Neutral
Disagree
Strongly Disagree
*
9.
How would you currently rate our community well-being in the Fox Cities?
(Required.)
Excellent
Very Good
Good
Fair
Poor
Excellent
Very Good
Good
Fair
Poor
*
10.
In five years from now, if we continue to do things the way we've always done them, what would you rate our community well-being to be?
(Required.)
Excellent
Very Good
Good
Fair
Poor
Excellent
Very Good
Good
Fair
Poor
11.
What do you think positively contributes most to our community well-being?
12.
What do you think hinders our community's potential well-being?
*
13.
In what community do you live? (e.g., city, town, village)
(Required.)
Appleton
Buchanan
Clayton
Combined Locks
Ellington
Fox Crossing
Freedom
Grand Chute
Greenville
Harrison
Hortonville
Kaukauna
Kimberly
Little Chute
Menasha
Neenah
Sherwood
Vandenbroek
Woodville
Other (please specify)
*
14.
What is your race?
(Required.)
White
Black or African American
Native American or American Indian
Asian/Pacific Islander
Multiple Races
Choose not to answer
Some other race (please specify)
*
15.
What is your ethnicity?
(Required.)
I am not Hispanic or Latino
Hispanic
Latino
Choose not to answer
*
16.
What is your age?
(Required.)
Under 18
18-23 years old
24-42 years old
43-54 years old
55-66 years old
67-73 years old
Over 74
Choose not to answer
*
17.
What is your gender?
(Required.)
Male
Female
Non-Binary
Choose not to answer
18.
Would you like to be kept up to date about Imagine Fox Cities?
*By your acknowledgment and the information shared below, you agree to receive periodic updates from Imagine Fox Cities. We do not share or sell the information you provide with anyone.
Yes
No
Contact Information:
19.
Email
20.
Phone Number
