Urban Living Environment Health Assessment Form
Please complete the Urban Living Environment Health Assessment Form to help us understand your experience and perceptions of your urban environment. Your responses will remain confidential and are used solely for assessment purposes.
How would you rate the air quality in your neighborhood?
*
1
2
3
4
5
How would you describe the level of noise in your living environment?
*
Very quiet
Mostly quiet
Moderate noise
Noisy
Very noisy
How accessible are green spaces or parks from your residence?
*
Very accessible (within 5 minutes)
Accessible (within 15 minutes)
Somewhat accessible (15-30 minutes)
Not easily accessible (over 30 minutes)
How satisfied are you with the cleanliness of public spaces in your area?
*
Very unsatisfied
1
2
3
4
Very satisfied
5
1 is Very unsatisfied, 5 is Very satisfied
Please rate the following aspects of your urban environment:
*
Rows
Poor
Fair
Good
Excellent
Street lighting
1
2
3
4
Sidewalk condition
5
6
7
8
Public transportation
9
10
11
12
Safety at night
13
14
15
16
Which type of housing do you currently reside in?
*
Apartment
Detached house
Townhouse
Other
How would you rate your sense of safety in your neighborhood during the day?
*
1
2
3
4
5
How would you rate the availability of essential services (e.g., grocery stores, healthcare, schools) nearby?
*
1
2
3
4
5
What is your main mode of transportation within the city?
*
Walking
Bicycle
Public transit
Personal vehicle
Other
Overall, how satisfied are you with your urban living environment?
*
Very unsatisfied
1
2
3
4
Very satisfied
5
1 is Very unsatisfied, 5 is Very satisfied
Submit Assessment
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