General Information Name of Interviewee Current Resident is the Owner of the Property a Tenant Name(s) on Deed/Title Community Physical 911 Address Parcel Identification Number Phone Number Type of Home Mobile/Manufactured Single-Wide Mobile/Manufactured Double-Wide 1 Story 2 Story 3 Story Age of Home Ownership Own Land and Home Rent Land and Own Home Rent Land and Home Individual Resident Please rank the items below in order of priority from 1 (highest priority) to 6 (lowest priority). If any are not applicable, mark "N/A". Home Repair Home Repair Home Accessibility/Handicap Modifications Home Accessibility/Handicap Modifications Water Quality Testing Water Quality Testing Well/Septic Installation or Repair Well/Septic Installation or Repair Trash Collection/Disposal Trash Collection/Disposal Other Other Other text Community Infrastructure Please rank the items below in order of priority from 1 (highest priority) to 10 (lowest priority). If any are not applicable, mark "N/A". Public Water/Sewer System Public Water/Sewer System Demolition of Vacant, Dangerous, or Condemned Structures Demolition of Vacant, Dangerous, or Condemned Structures Drainage Improvements Drainage Improvements Community Center Repairs Community Center Repairs Community Center Accessibility Community Center Accessibility Street Lights Street Lights Sidewalks Sidewalks Street/Road Improvement Street/Road Improvement Public Transportation Public Transportation Other Other Other text Community Services Please rank the items below in order of priority from 1 (highest priority) to 5 (lowest priority). If any are not applicable, mark "N/A". After-School Programs After-School Programs Financial Literacy Education Financial Literacy Education Animal Control Services Animal Control Services Light Code Enforcement Light Code Enforcement Other Other Other text Household Demographic Information Number of People in Household Number of People under Age 18 Number of Disabled Persons in Household Female Head of Household Yes No Gross Annual Household Income Person 1 Gender - None -MaleFemale Race - None -WhiteBlack or African AmericanAsianAmerican Indian or Alaska NativeNative Hawaiian or Other Pacific IslanderOther Multi-RacialChoose Not to Respond Ethnicity - None -HispanicNon-Hispanic Person 2 Gender - None -MaleFemale Race - None -WhiteBlack or African AmericanAsianAmerican Indian or Alaska NativeNative Hawaiian or Other Pacific IslanderOther Multi-RacialChoose Not to Respond Ethnicity - None -HispanicNon-Hispanic Person 3 Gender - None -MaleFemale Race - None -WhiteBlack or African AmericanAsianAmerican Indian or Alaska NativeNative Hawaiian or Other Pacific IslanderOther Multi-RacialChoose Not to Respond Ethnicity - None -HispanicNon-Hispanic Person 4 Gender - None -MaleFemale Race - None -WhiteBlack or African AmericanAsianAmerican Indian or Alaska NativeNative Hawaiian or Other Pacific IslanderOther Multi-RacialChoose Not to Respond Ethnicity - None -HispanicNon-Hispanic Person 5 Gender - None -MaleFemale Race - None -WhiteBlack or African AmericanAsianAmerican Indian or Alaska NativeNative Hawaiian or Other Pacific IslanderOther Multi-RacialChoose Not to Respond Ethnicity - None -HispanicNon-Hispanic Person 6 Gender - None -MaleFemale Race - None -WhiteBlack or African AmericanAsianAmerican Indian or Alaska NativeNative Hawaiian or Other Pacific IslanderOther Multi-RacialChoose Not to Respond Ethnicity - None -HispanicNon-Hispanic Person 7 Gender - None -MaleFemale Race - None -WhiteBlack or African AmericanAsianAmerican Indian or Alaska NativeNative Hawaiian or Other Pacific IslanderOther Multi-RacialChoose Not to Respond Ethnicity - None -HispanicNon-Hispanic Person 8 Gender - None -MaleFemale Race - None -WhiteBlack or African AmericanAsianAmerican Indian or Alaska NativeNative Hawaiian or Other Pacific IslanderOther Multi-RacialChoose Not to Respond Ethnicity - None -HispanicNon-Hispanic Leave this field blank
