Survey(3).doc

Address:

SURVEYOR NAME:______________________________________________

SURVEY DATE:_________________________________________________

SURVEY TIME:__________________________________________________

OUTCOME & OCCUPANCY (choose one):

1. _____Completed & Occupied

2. _____Refused but Occupied

3. _____Appears to be Occupied 4. _____Appears to be Unoccupied

4. _____Business 5. _____Vacant Lot

PROXY OCCUPANCY INFO (choose one, if possible):

6. _____Neighbor (proxy) confirmed Occupied 7. _____Neighbor (proxy) confirmed Unoccupied

Introduction and Consent Form

Introduction (To be read to household residents at least 18 years of age)

Hi. My name is ___________. I'm working with the RALLY Foundation to collect information that will be used to bring programs and services to Central City. The results will be provided to the Community Safety Initiative, which is a group of community groups and other non-profit foundations interested in providing services to the neighborhood.

This is a great opportunity for you to share your views about the recovery and rebuilding of New Orleans and especially your neighborhood. While we understand that you are very busy, we ask for no more than 10 minutes of your time to complete this survey and share your views. We will provide you with a $5 incentive card from Wal-mart when you complete this survey.

Consent to Participate in Survey

Your participation in this research is entirely voluntary. You do not have to participate. If at any time you do not want to answer an interview question, you do not have to do so. You are free to stop the interview at anytime.

You are free to ask questions before agreeing to participate. We will need you to initial this consent form to show that you agree to participate. Your answers will remain confidential. Though we will be writing down your address on the surveys we will keep all surveys in a locked file cabinet. To keep your information confidential we will assign a unique ID # to your address so that all data we enter into our computer will list the ID # we've assigned to your address and not your actual address. A list linking ID #'s to actual addresses will be kept in a locked file cabinet to be accessed only by key research personnel.

Would you like to participate in this survey? I will provide you with contact information in case you would like to ask us any questions.

INTERVIEWER: Note down any questions he or she asks:

_____________________________________________________________________________

Participant's initials ___________________

1. What is the race or ethnicity of your household?

2. Do you own this residence or rent?

1. Own

2. Rent

3. Other, specify____________

3. Do you receive your mail at this address?

Yes No

3.a. If No, where do you receive mail? _________________________________

4. How many people are currently living in your household including yourself? _____

5. What are the greatest problems your household has faced since Katrina which are still problems today? ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

7. Are you aware of a community center that serves your neighborhood in any of these ways we just talked about?

Yes No Don't know

7.a. If so, where? _____________________________________

7.b. and, do you use it?

Yes No Don't know

7.c. If not, would you use one if there was?

Yes No Don't know

8. If there were a community center that offered some of these services located on Broad and Washington in Central City would you go there?

Yes No Don't know

9. How about JW Hoffman School near Taylor Park?

Yes No Don't know

10. How about at Jackson and Simon Bolivar in Central City?

Yes No Don't know

11. Is there another location for a community center which would be better?

Yes No Don't know

11.a. If so, where? _____________________________________

13. Do you feel it is important to open JW Hoffman School?

Yes No Don't know