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. 

 

1. 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
2. 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
3. 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
4. How many children currently reside in your home?
5. What is your zip code?
6. 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+
7. 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
8. What is your gender? Male Female Prefer Not to Answer
9. What is your email address?
10. Please indicate your age range Under 18 18 - 25 26 - 49 50 - 65 Over 65
11. Leave this field empty to prevent spam: