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* 1. Please enter the address of the survey location. (555 Main Road New City, MD 55555)

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* 2. How many of your family members graduated college?

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* 3. How would you characterize your family's wealth?

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* 4. How old are you?

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* 5. How close do you live to a store that sells fresh fruits and vegetables?

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* 6. When grocery shopping, do you know how to read the food package nutrition facts?

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* 7. Are any of these food outlets near you?

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* 8. Does your family live near a community garden?

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* 9. Do you, or members of your family know their Body Mass Index (BMI)?

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* 10. The following programs/services are offered at the survey location:

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* 11. Do you live near a sports and recreation center or private sports facility?

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* 12. How safe is your neighborhood?

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* 13. In general, is the neighborhood:

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* 14. Within a one block radius of this building, how many times have you seen, heard, or experienced criminal activity in the last three months?

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* 15. If you have seen criminal activity, what type(s)?

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* 16. Do you think gangs or crews are active in this neighborhood?

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* 17. Is there graffiti on this block?

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* 18. Are there sidewalks on this block?

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* 19. Is there a bus stop on this block?

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* 20. Is there a fire hydrant on this block?

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* 21. Are there abandoned/boarded-up buildings on this block?

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* 22. Is there an unsignalized cross-walk on this block? (painted cross-walk without a stop sign or signal)

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* 23. Are there outdoor parks or recreation areas on this block?

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* 24. What kinds of services/businesses would you like to see in this neighborhood, if any?

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