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Post-Tour Survey
Thank you for visiting the safety demonstration home today. We hope you enjoyed your tour.
Please complete this brief survey. Your feedback is very important to us.
During your Safety Demonstration House tour, did you discover any areas/issues in your own home that are potential safety risks to a child?
Yes
No
Do you feel that Charlie's House provided you with or directed you to the resources you need to make your home safe?
Yes
No
As a result of what you learned from Charlie's House, will you be taking action to help prevent an accident or injury in and around your home?
Yes
No
How many children currently reside in your home?
What is your zip code?
What are the ages of the children that reside in your home? (select all that apply)
Expecting
Newborn
1-3
4-8
8-12
13+
What is your ethnic background?
Asian or Pacific Islander
Black or African American
Hispanic or Latino
Native American or Alaskan Native
White or Caucasian
Multiracial or Biracial
Prefer Not to Answer
What is your gender?
Male
Female
Prefer Not to Answer
What is your email address?
Please indicate your age range
Under 18
18 - 25
26 - 49
50 - 65
Over 65
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