Name

Phone number

Date

How concerned are you about climate change?

• Very Concerned

• Somewhat Concerned

• Neutral

• Not Very Concerned

• Not Concerned at All

What do you believe is the main cause of climate change?

• Human activity (e.g., burning fossil fuels)

• Natural processes

• Both human and natural factors

• Unsure

Have you noticed any changes in your local environment due to climate change?

What actions have you personally taken to reduce your carbon footprint?

Check all that apply.

• Reduced energy consumption

• Used public transportation or carpooling

• Recycled more

• Adopted renewable energy sources

• None

How important do you think it is for governments to address climate change?

• Extremely important

• Somewhat important

• Neutral

• Not very important

• Not important at all

Do you support policies aimed at reducing carbon emissions?

Would you be willing to adopt lifestyle changes (e.g., reduce waste, use eco-friendly products) to help combat climate change?

What do you think is the most effective way to combat climate change?

• Government action and policies

• Individual lifestyle changes

• Corporate responsibility and innovation

• Global collaboration

How often do you talk about climate change with friends or family?

• Frequently

• Occasionally

• Rarely

• Never

What additional resources or information would you like to receive on climate change?

• Articles and research

• Workshops and seminars

• Policy updates

• Environmental organizations and initiatives