How much do you agree with each of the following statements? (circle your response)

1 = strongly disagree2 = disagree3 = neutral4 = agree5 = strongly agree

With respect to pesticides on food:
12345This is an important issue to me
12345I'd like to know more
12345The government should do more to inform me
12345Grocery stores should provide more information
12345I can't do much about my exposure
12345Children are at higher risk than adults
12345I am not concerned about how they may affect my family
12345I consider myself well-informed
12345A grocery store is a useful place to distribute information

How often do you do the following? (circle your response)

1 = never 2 = rarely 3 = sometimes 4 = most of the time5 = always

12345Wash fruits and vegetables
12345Peel fruits and vegetables that have a skin that you can eat
12345Purchase organic food
12345Ask your grocer about food that is grown using fewer or no pesticides

Where have you gotten information about pesticides on food in the past? (check all that apply)

___Radio ___Public Library ___Television News ___Newspaper
___Magazine ___Friends/Family ___Grocery Store ___Internet
___Medical Doctor ___School ___Have not gotten information, until now  

If you could recommend where to distribute information about pesticides on food, where would you suggest?
(circle your selection(s) from the above list)

From the following list choose the five issues that are most important to you and rank them on a scale of 1 to 5:
1 = most important issue and 5 = least important issue

___Loss of natural and scenic areas ___Endangered species
___Depletion of the ozone layer ___Air pollution
___Pesticide use on foods ___Disposal of hazardous waste
___Acid rain ___Drinking water contamination

Please check the appropriate response:

Gender: ___M ___F

Age: ___18-19 ___20-24 ___25-29 ___30-34 ___35-39 ___40-44 ___45-49 ___50-54
  ___55-59 ___60-64 ___65 & over          

Schooling Completed: ___Some High School ___High School Diploma or GED ___Some College
  ___4-year College Degree ___Post-Graduate Degree  

Yearly Household Income: ___Under $15,000 ___$15,001 - $18,000 ___$18,001 - $21,000
___$21,001 - $24,000 ___$24,001 - $27,000 ___$27,001 - $30,000 ___$30,001 - $35,000
___$35,001 - $40,000 ___$40,001 - $50,000 ___$50,001 - $60,000 ___$60,001 - $70,000
___$70,001 - $80,000 ___$80,001 - $90,000 ___$90,001 - $100,000 ___$100,001 and Over

I consider myself: ___Asian American ___Latino/Hispanic ___Black/African American
  ___Native American ___White/Caucasian ___Other

Number of children in household (under age 18):_____ Number of adults in household (age 18 & over):_____

Please add any other comments.  

Please return your completed survey to: Pesticides on Food Survey
School of Natural Resources & Environment
University of Michigan
Dana Building 430 E. University
Ann Arbor, MI 48109-1115

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