A community survey questionnaire takes into account the various issues and problems that people of a certain community faces within a particular municipality or city or state. The community survey is conducted by social organizations, community bodies, and even by government civic agencies. The answers received from a community survey questionnaire helps civic and social organizations in determining what steps can be taken to solve critical community issues.

Sample Community Survey Questionnaire:

Name of the Participant: _____________________________

Gender: _________________ (M/F) |  Age: ___________

Occupation:__________________ Marital Status: _________________________

Address: ______________________________________  City:_______________

State: __________________  Zip: ________________

Email: _____________________________

Phone Number: ____________________________

  • Which of the following pollutions needs to be checked in your community or area?

a)      Air Pollution

b)      Water Pollution

c)      Littering

d)     Noise pollution

e)      Soil contamination

  • In the last 5 years, which of the following pollutants have lead to disease or serious illness in your community?

a)      Pesticides

b)      Industrial pollutants

c)      Untreated sewage

d)     MTBE

e)      Underground oil spills

f)       Underground chemical spills

g)      Chemical spill in the river

h)      High carbon monoxide concentration in air

i)        Poisonous gas released by vehicles

  • Are you satisfied with the quality of the drinking water supplied by public works department?

a)      Extremely Satisfied

b)      Somewhat Satisfied

c)      Neutral

d)     Somewhat Dissatisfied

e)      Very Dissatisfied

f)       Extremely Disappointed

  • Which of the other following areas needs to be looked into by the social community board?

a)      Transportation for elderly

b)      Transportation for children

c)      Playgrounds for children

d)     Sports and fitness center

e)      Basic civic amenities

  • Are you satisfied with the existing condition in any of the following areas? (Please specify with Y/N in front of each statement)

a)      Tree lining or cover in the community

b)      Plenty of Green cover / Green area

c)      Kitchen gardens and organic food

d)     Healthy bird population

e)      Healthy insect population

f)       Several families have pets