Name (Optional)

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How concerned are you about climate change?

• Very concerned

• Somewhat concerned

• Not concerned

Have you made any changes to reduce your carbon footprint?

What actions do you take to reduce environmental impact?

Select all that apply

• Use energy-efficient appliances

• Reduce, reuse, recycle

• Use public transportation or carpool

• Reduce water usage

• Support renewable energy sources

How much do you think individual actions contribute to fighting climate change?

• A lot

• A little

• Not at all

Would you like to learn more about how to reduce your environmental impact?

Additional Comments/Suggestions