Perceptions of Your Neighborhood

Please fill out the survey below or you may print out the form.

Your Neighborhood? *
Zip Code
Number of Years Living in this Neighborhood?
Your Age?
Please list the things in your neighborhood that make you healthy and strong.
Type 3 answers
Please list the things in your neighborhood that make you unhealthy or unwell.
Type 3 answers
What is the best thing about your neighborhood?
What is the worst thing about your neighborhood?
What would you say are the top causes of illness in your neighborhood?
Type 3 answers.
Do you think anything needs to be changed in your neighborhood?
YesNo
If yes, what would you most like to see changed in your neighborhood?
What do you think most people die from in your neighborhood?
Type 3 answers
If interested in participating in neighborhood conversations related to health and wellness in your neighborhood, please check Yes/No.
YesNo
Please feel free to contact Community Empowerment Association at 412-371-3689 for more details.
Name *
Email *
Phone
Would you like to be contacted?
YesNo

PERCEPTIONS OF YOUR NEIGHBORHOOD