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The Neighborhood Quality of Life Study
Experience Feedback Form
1. Please rate your degree of satisfaction as a participant?

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Dissatisfied
Neutral
Satisfied
Very Satisfied
2. What did you like best?
3. What did you like least?
4. How can we improve?
5. Please tell us a story how your neighborhood affects your health and quality of life. (optional)

6. Name: (optional)  
Yes
No 		The Neighborhood Quality of Life Study (NQLS) likes to use stories from participants in lectures, printed publications, and its web site on how your neighborhood affects your health and quality of life. May we use your name with your comments in association with our study in the any of the media listed above?