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Please read the enclosed brochure Pesticides and Food
before completing this survey.
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Had you seen the brochure Pesticides and Food before you received this survey? Yes
No Not Sure
If yes, where? ______________________________
How much do you agree with each of the following statements? (circle your response) |
1 = strongly disagree2 = disagree3 = neutral4 = agree5 = strongly agree
I found the material in this brochure:
12345Easy to understand
12345Interesting
12345Informative about reducing my risks
12345Did not give enough information
12345Frustrating
12345Mostly about things I already know
12345Informative about reducing children's risks
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 likely do you think people are to do the following? (circle your response) |
1 = very unlikely2 = unlikely3 = uncertain4 = likely5 = very likely
12345Read this brochure if they saw it in a grocery
store
12345Use the contact information in the brochure to
get more information about pesticides
12345Tell other people about the information in this
brochure
12345Pass this brochure on to other people
12345Call a toll-free telephone number to get more
information about pesticides
12345Go to the EPA website for more information about
pesticides
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 |
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___Other |
___________________________________________________________________________ |
If you could recommend to the EPA where to distribute this information, where
would you suggest?
(circle your selection(s) from the above list)
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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: |
Age: |
___18-19 |
___20-24 |
___25-29 |
___30-34 |
___35-39 |
___40-44 |
___45-49 |
___50-54 |
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___55-59 |
___60-64 |
___65 & over |
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Schooling Completed: |
___Some High School |
___High School Diploma or GED |
___Some College |
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___4-year College Degree |
___Post-Graduate Degree |
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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 |
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___Native American |
___White/Caucasian |
___Other |
Number of children in household (under age 18):_____ |
Number of adults in household (age 18 & over):_____ |
Any suggestions for changes to the brochure? |
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Please add any other comments. |
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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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