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Hello:

You are invited to participate in our survey [Project Description Here]. In this survey, approximately [Approximate Respondents] people will be asked to complete a survey that asks questions about [General Survey Process]. It will take approximately [Approximate Time] minutes to complete the questionnaire.


Your participation in this study is completely voluntary. There are no foreseeable risks associated with this project. However, if you feel uncomfortable answering any questions, you can withdraw from the survey at any point. It is very important for us to learn your opinions.


Your survey responses will be stricly confidential and data from this research will be reported only in the aggregate. Your information will be coded and will remain confidential. If you have questions at any time about the survey or the procedures, you may contact [Name of Survey Researcher] at [Phone Number] or by email at the email address specified below.


Thank you very much for your time and support. Please start with the survey now by clicking on the Continue button below.


 
 
 
Favorite Drink...
 
Coke
 
Pepsi
 
Sprite
 
Mountain Dew
 
A&W Root Beer
 
Other Comments :

 
 
 
What is your approximate age?
 
18 - 24
 
25 - 34
 
35 - 44
 
45 - 54
 
55 - 64
 
65 and over
 
 
 
Indicate your marital status.
 
Single
 
Married
 
Widowed
 
Divorced
 
 
 
Please indicate your approximate yearly household income before taxes. (Include total income of all adults living in your household.)
 
Under $25,000
 
$25,001 - $49,999
 
$50,000 - $74,999
 
$75,000 - $99,999
 
$100,000 -$149,999
 
$150,000 and over
 
 
 
What was the last grade you completed in school?
 
Some high school
 
High school graduate
 
Some college
 
College graduate
 
Postgraduate/professional
 
 
 
Please indicate the number of children in your household under the age of 18.
 
None
 
One
 
Two
 
Three
 
Four or more
 
 
 
Including yourself, how many persons are in your household?
 
One
 
Two
 
Three
 
Four
 
Five or more
 
 
 
What is your current work status?
 
Work outside home full time
 
Work outside home part time
 
Do not work outside home
 
 
 
What is the present occupation of the head of household?
 
Professional/technical
 
Manager/official/proprietor
 
Clerical
 
Sales
 
Crafts/trades
 
Operator
 
Laborer
 
Service worker
 
Retired
 
Homemaker
 
Student
 
Unemployed
 
Other
 
 
 
Please write in your ZIP Code.
   
 
 
 
Tell us how often you visit our site.


 
Everyday
 
Once a week
 
Once in two weeks
 
Once a month
 
Rarely
 
Other
 
 
 
 
When you visit the site, are you using the computer from



 
Office
 
Home (including a home office)
 
Equally from the home and office
 
Other
 
 
 

Please tell us why you visit our site (please check all that apply)?
 
Looking for general information
 
Looking for rules/regulations
 
Looking for forms
 
Looking for facility information
 
Looking for regulatory information
 
Looking for Upgrade Information
 
Looking for Qualified Professional/Consultant Information
 
Looking for news (Meetings, Seminars, Calendar, Public Hearings etc)
 
Looking for Contact Information (Agency and Staff Phone #s, Mailing Address etc)
 
Research for Work
 
Research for School
 
Download files
 
Professional Development
 
Looking for update on earlier information
 
Other
 

 
 
 
How much effort did you have to take to find our web site?

 
A lot less than I expected
 
Less than I expected
 
About what I expected
 
More than I expected
 
A lot more than I expected
 
 
From what you have seen and your experience with other sites, please rate the following features of the web page:
Poor Fair Good Very good Excellent Not sure
Visual appearance/layout:
Content:
Writing style:
 
 
 
From your experience, what do you find to be the biggest challenge with using our site?






 
I am new to the Internet
 
Information I am looking is not available
 
Information is not well organized
 
There is just too much information
 
Hard to navigate through the information
 
Takes too long to load a page
 
Downloadable files or forms are in a format I cannot use
 
Other (please specify)
 
 
 
 
Did the menu of items on the home page make sense to you?

 
Yes
 
No
 
 
 
How did you hear about the Website?




 
Hotline
 
Industry consultants
 
Newsletters/literature
 
Media (newspaper, radio, TV)
 
Associate/friend
 
Followed Link from another web page
 
Search engine
 
Other (Please Specify)
 
 
 
 
We would like to hear your suggestions on how we can expand or improve our site. What additional information or features would you like to see added to the site?
   
Email
   
 
 
 
In general, do you feel that gasoline prices are:
 
much too high
 
somewhat high
 
about right
 
 
 
What is the most important reason for purchasing premium grade gasoline?
 
like the extra power
 
use to clean my engine
 
engine requires premium grade
 
towing/pulling
 
it's just better for my car
 
my car is older and runs better on premium
 
 
 
When you need to purchase gasoline, do you most often purchase it:
 
on your way to work
 
on your way home from work
 
on your way to go shopping
 
on your way home from shopping
 
while you are out doing errands
 
when making a special trip to the gas station
 
 
 
Think about the gasoline station you go to most often. Is it closer to
 
your home
 
your place of work
 
your favorite shopping area
 
 
 
Again think about the gas station you go to most often. What are some reasons this gas station is your favorite? (Check all that apply)
 
convenient location
 
convenient hours of operation
 
close to work
 
close to home
 
close to favorite shopping area
 
lowest prices
 
fast payment
 
fast in and out
 
happy with brands
 
have credit card for that brand of gas
 
like the food mart
 
friendly service
 
other
 
 
 
In an average month, about how much does your total household spend on gasoline?
 
less than $25
 
$25 - $50
 
$50 - $75
 
$75 - $100
 
over $100
 
 
 
Do you have a gasoline card?
 
Yes
 
No
 
 
 
About what part of the amount you pay for gasoline is spent using
gasoline cards
VISA/Mastercard
Other credit card
Cash
Check
Other payment
0
 
 
 
What are the three best features you would expect to get with a gasoline card?
 
generous grace period
 
bonus gas to reward frequent purchases
 
low interest rate
 
use for several different gasoline companies
 
easy to get one
 
end of year rebate
 
free car washes

 
 
 
Approximately how many times did you shop for electronic products in the past year?
   
 
 
 
Please indicate the approximate total amount your family spent on electronic product within the last year.
 
Less than $300
 
$300 - $499
 
$500 - $799
 
$800 - $999
 
$1,000 - $2,499
 
More than $2,500
 
Can't say
 
 
 
During the past year, have you or a member of your family purchased a major home electronic product?
 
Yes
 
No
 
 
 
If yes, what item was purchased? (Check all that apply.)
 
TV
 
Microwave
 
DVD player
 
Laptop
 
Home Computer
 
Other
 

 
 
 
How much did you pay for the item(s)?
   
 
 
 
How many brands or individual models did you examine in the different retail stores?
   
 
 
 
The item was purchased:
 
As a gift for someone not in your household.
 
As a gift for someone in your household.
 
To be used mostly by other members of your household.
 
To be used mostly by yourself.
 
Other
 
 
 
Which of the following have you purchased within the last year? (Check all that apply)
 
Microwave
 
audio/car stereo/radio/cassette
 
Calculator
 
Video game
 
Computer
 
Phone
 
TV
 
VCR/DVD
 
Camera
 
Other
 
 
 
pick only one answer please
* how often do you and/or your family go to a restaurant for a meal?
 
every week
 
every two weeks
 
at least once a month
 
less than once a month
 
 
choose as many as apply please
* which of the following apply to you?
 
i have young children and it is hard to find a restaurant with facilities and menus suitable for children
 
i have young children and it is easy to find restaurants with facilities and menus for children
 
i am currently in a relationship and enjoy going out with my partner for a romantic meal
 
i enjoy going out for a meal in a restaurant with a fun atmosphere
 
i enjoy going out for a meal with a serious atmosphere
 
if you enjoy other types of restaurant please say
 

 
 
 
* how far would you be prepared to travel to get to a good restaurant?
 
5 miles
 
10 miles
 
20 miles
 
50 miles
 
Other
 
 
 
 
which social status do you fall into?
 
unemployed
 
recieving education
 
part time job
 
full time job
 
Other
 
 
 
Below is a list of statements. Please indicate how you feel about each statement by indicating your degree of agreement or disagreement with each statement.
Strongly agree Agree Neutral Disagree Strongly disagree Not sure
Financial security is very important to me.
I'd say I'm rebelling against the way I was brought up.
I believe that "industrial growth" should be limited.
Generally speaking, most people are trustworthy and honest.
Everything is changing too fast today.
In general, it's more important to understand my inner self than to be famous, powerful, or wealthy.
My greatest achievements are ahead of me.
I believe a woman can work outside the home even if she has small children and still be a good mother.
I certainly am more conventional than experimental.
I like to try new and different things.
Strongly agree Agree Neutral Disagree Strongly disagree Not sure
It's very important to me to feel I am a part of a group.
Overall, I'd say I'm very happy.
TV is my main form of entertainment.
I'm a "spender" rather than a "saver."
I would rather spend a quiet evening at home than go out to a party.
My family is the single most important thing to me.
I think I have more self-confidence than most people.
I like to think I'm a bit of a swinger.
A woman's life is fulfilled only if she can provide a happy home for her family.
My social status is an important part of my life.
I act on my hunches.
 
 
 
Strongly Disagree Disagree Neutral Agree Strongly Agree Not sure
I generally rent movies.
I usually enjoy rated R films more than I enjoy PG 13, PG, or G movies.
Students/kids viewing too many murders and crimes in movies has increased the number of crimes amongst youth.
Movies without violence are less appealing to me.
Profanity is not needed in films.
Sexual content in movies makes them more entertaining.
Movies are a direct reflection of the values in today�s American Society.
I would be interested in software that gives me the option to control the sexual content, profanity, and violence in DVD movies.
Based upon the premise that the software existed to give me more control and added features for movies on DVD format, I would purchase a DVD player for this purpose.
As a parent, I would like more control over what my children watch in movies. (if not a parent, answer as if you were one)
I generally buy movies.
 
 
 
What is your idea of a good night out?
 
Visit to the theatre or opera
 
Romantic dinner for two
 
Karaoke at the local pub
 
Drinks and then clubbing
 
Watching a football game
 
Other
 
 
 
 
Which of these would be your ideal holiday?
 
Activity-based, e.g. skiing
 
A luxury hotel in New York
 
Exploring the Far East
 
Lying on a beach in the sun
 
A cottage in the country
 
Other
 
 

This is the questionnaire that deals with health care and your involvement in health care. Please take a few minutes to express your opinions about the availability and quality of health care in your community. Your answers are important to the success of this study.



Thank you for your assistance.
 
 
 
Which community (or rural area) do you live?
   
 
 

Is there a wide difference in performance between the available hospitals in this area?
 
Yes
 
No
 
Not sure
 
 

Do you have a favorite hospital?
 
Yes
 
No
 
 

Is there a wide difference in the cost of the different hospitals in this area?
 
Yes
 
No
 
Not sure
 
 
 
How many years have you lived in this community?
   
 
 

How satisfied are you with the skill and competency of the staff?
 
Very satisfied
 
Somewhat satisfied
 
Neutral
 
Somewhat dissatisfied
 
Very dissatisfied
 
Not sure
 
 

Does the hospital have equipment for modern diagnosis and treatment?
 
Yes
 
No
 
Not sure
 
 

How satisfied are you with the following:
Overall cleanliness of the hospital
 
Very satisfied
 
Somewhat satisfied
 
Neutral
 
Somewhat dissatisfied
 
Very dissatisfied
 
Not sure
 
 

Friendliness and courtesy of the staff
 
Very satisfied
 
Somewhat satisfied
 
Neutral
 
Somewhat dissatisfied
 
Very dissatisfied
 
Not sure
 
 

Convenience of location for you
 
Very satisfied
 
Somewhat satisfied
 
Neutral
 
Somewhat dissatisfied
 
Very dissatisfied
 
Not sure
 
 

Cost to you
 
Very satisfied
 
Somewhat satisfied
 
Neutral
 
Somewhat dissatisfied
 
Very dissatisfied
 
Not sure
 
 
 
What kind of medical insurance coverage do you have?
 
None
 
Private
 
Employer sponsored
 
Medicaid
 
Medicare
 
Not sure
 
Other
 
 
 
 
How many times have you and any member of your family been to your doctor in the last year?
   
 
 
 
Which source of care would you prefer if you had a personal injury that could be handled equally well by each of these sources of health care:
 
I would prefer to go to a walk-in clinic
 
I would prefer to go to my personal physician
 
I would prefer to go to the hospital emergency room
 
Other
 
 
 
 
If you or a member of your family have received medical care at a hospital that was'nt the hospital in your area, why did you choose the other hospital?
 
A specialist was available
 
Special hospital care was required that was not available in the local area
 
My physician practices there
 
More familiar with that hospital
 
Wanted a second opinion from another physician
 
Religious preference
 
Cost was too high in the local area
 
Other
 
 
 

Is your home
 
a single family house
 
a two family house
 
an apartment
 
a mobile home
 
Other
 
 
 
 
Indicate activities/interests which you and/or household members enjoy on a regular basis:
 
Bicycling/running
 
Camping
 
Dieting
 
Crafts
 
Foreign travel
 
Gourmet/fine food
 
Coin/stamp collecting
 
Fashion clothing
 
Bible/devotional reading
 
Physical fitness/exercise
 
Stereo/records and tapes
 
Sweepstakes
 
Sewing
 
Needlework/knitting
 
Art/antiques
 
Outdoor gardening
 
Wildlife/environment issues
 
Do-it-Yourself/workshop
 
Recreational vehicles
 
Health foods/vitamins
 
Money making opportunities
 
Video cassette recordings
 
Book reading
 
Self improvement
 
Compact discs
 
Watching sports on TV
 
Charities/volunteer work
 
Other
 
Please contact [email protected] if you have any questions regarding this survey.
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