Background Information (Optional)

1. Household income level (per year):
   Less than $12,000 $12,001 - $20,000 $20,001 - $30,000
   $30,001 - $40,000 $40,001 - $50,000 $50,001 - $75,000
   $75,000 - $100,00 More than $100,000
2. Do you own your home? Yes No
3. Do you receive any form of government assistance with your utility bill?
   Yes No
4. Are you over age 55? Yes No
5. Do you receive disability income? Yes No
6. Do you receive Social Security Income? Yes No

Survey Questions

1. How much does the higher cost of energy affect you?
   Not at all Very Little Slightly Some A lot
2. Will you be able to pay for the higher cost of energy? Yes No
3. Please describe in the space below what ways will the higher cost of energy affect you and your family?
   
4. Will the rising cost of gasoline limit your ability to go to work or perform necessary errands?
   Yes No
5. What do you plan to do about the higher cost of gasoline?
   
6. With more money going to energy costs will you have to sacrifice other purchases? Yes No
7. If you answered yes to the above question, what items will you avoid purchasing so you can pay for energy costs?
   
8. Where do you get the most reliable information about energy?
   State or Federal Government
   Cooperative Extension Service
   Newspaper, Radio or TV
   Utility Company
   Other
9. What steps are you taking to reduce your energy costs? (Check all that apply)
   Driving less or Carpooling
   Turning my thermostat down
   Adding home conservation measures (like more insulation, etc)
   Spending less so I can afford energy
   Not sure what to do
   Other
10. What short-term solutions would be most useful to you? (Check all that apply)
    Tips about things I can do to save energy and money.
    Help in paying for my home heating
    Help in making my home more energy efficient
    Utility company discounts
    Other
11. What long-term solutions would be most useful to you? (Check all that apply)
    Alternative energy like wind and solar
    More efficient cars
    Reduce cost of energy
    Mass Transportation (buses, trains, etc)
    Other
12. Please enter any additional thoughts you have about energy costs below.
    

Thank you for your time in completing this survey. Your input is important and appreciated.