Exploratory Psychosocial Survey For Communities With At Least One Polluting Industry or Faced With the Potential Location of a Polluting Industry

Hello, my name is Therese Vick, the Healthy, Sustainable Communities Coordinator for Blue Ridge Environmental Defense League (BREDL). BREDL is a regional grassroots environmental organization. My academic work in the human services field and my experience with threatened and impacted communities led me to develop this survey to find out if environmental issues in the community affect people’s mood and sense of well being. The results of this survey may be used to inform communities and policy makers about the potential effects of environmental issues on community well-being.

I am recruiting individuals for a short questionnaire which will include 5 demographic questions and 32 survey questions. It will take approximately 30-45 minutes to complete.

If you choose to share your name or other personal information with the researcher, be assured that your name, address, or other identifying information will not be published or given to other parties except those connected with this research study. All individual results are strictly confidential. Only the overall (aggregated) results of the survey will be available. If you wish to identify your responses as coming from a particular community or organization please note this in the text box located at the end of the survey under the "Thank You."

Your participation in this study is voluntary. If you have any questions concerning the survey, please call me at (919) 345-3673, or email me at therese.vick@gmail.com.

Thank You Very Much.

    Confidentiality Agreement

    I understand that by taking this survey I am indicating that I participated voluntarily. I also give the researcher permission to publish the results of the survey, which will include data collected from me. I also understand that my personal information will not be shared with anyone without my written permission.

    The Survey

    The following questions will help the researcher understand more about you and where you live. Some, but not most questions will require that you provide an answer. These questions will have a "rather not say" or other option. Although you are not required to answer every question, in order to get a complete picture of what you are experiencing, answering each question to the best of your ability is very important. Remember, any identifying information will be confidential.
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    Environmental Information

    Questions one through seven pertain to the possibility of a company, pipeline, landfill, fracking well, etc moving into your community.
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    Mood and Well Being

    The following questions will ask you about your moods and feelings. Please rate how often you have each feeling on a scale from one to five. One being “never”, two being "once a month", three being "once a week", four being "several times a week", and five being "daily". Please answer the next question as accurately as you can before beginning the mood assessment.
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    Sleep

    The next questions will ask about your sleep. Please choose from one to five with one being “never", two being “once a month,” three being “once or twice a week,” four being “most nights of the week,” and five being "always.” Please answer the next question as accurately as you can before beginning the sleep assessment.
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    Community Involvement

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    Thank You

    Thank you very much for your participation in this study. The results could help policymakers and understand the effect that polluting industries have on quality of life and feelings of well-being as well as the environment.
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