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ROTARY CLUB OF __________________________________
ROTARY COMMUNITY SERVICE BUSINESS SURVEY FORM Date ___________________ Interviewer ______________________ Company Name_____________________________ Classification _______________________ Person Interviewed____________________________ Title ______________________ Card ____ Position: SUPERVISOR MANAGER Other _____________________ OWNER ___ PRTNR ___ Location _______________________________________________ Phone: __________________ Email: ________________________________________________ (Cell:) __________________ Ask for the owner/manager/supervisor; Get their name from receptionist/assistant, and ask for their business card immediately. [This provides most of the above information that you need for your permanent community business data base] "Mr/Ms (business/office owner) ____________, I'm (Rotarian surveyor)__________, from the Rotary Club of __________, ...and we're doing a community service survey of ___(name of community)__." "The efficient use of time is an essential concept to us in Rotary. I need just ___ minutes of your time to help us, and possibly to help you. OK?" "Fine; thanks; first: How long have you been in business? _____ yrs How many employees?_____ FT ___ PT ___ How many are permanent? ____ How many are under age 30? ____ How many have been with you ____ yrs or more? _______ "What do you see is the #1 community concern or need? ______________________________________ "What would your employees consider the #1 concern in this community? ________________________ ______________________________________________________________________________________ "What is your general feeling regarding the following issues in your community?" Most important + Least important -- BUSINESS HEALTH? ............ 10 9 8 7 6 5 4 3 2 1 0 ________________________ CAPITAL RESOURCES ......... 10 9 8 7 6 5 4 3 2 1 0 ________________________ COSTS _________________ 10 9 8 7 6 5 4 3 2 1 0 ________________________ WAGE LEVELS? .................. 10 9 8 7 6 5 4 3 2 1 0 ________________________ EMPLOYEE BENEFITS .......... 10 9 8 7 6 5 4 3 2 1 0 ________________________ RAW MATERIALS/FUEL ....... 10 9 8 7 6 5 4 3 2 1 0 ________________________ TAXES: _____ _____ _____. 10 9 8 7 6 5 4 3 2 1 0 ________________________ TRANSPORTATION ............... 10 9 8 7 6 5 4 3 2 1 0 ________________________ ADVERTIZING/PROMOTION .. 10 9 8 7 6 5 4 3 2 1 0 ________________________ COMPETITION: For/Dom ........ 10 9 8 7 6 5 4 3 2 1 0 ________________________ TRAFFIC CONGESTION ........ 10 9 8 7 6 5 4 3 2 1 0 ________________________ BUSINESS ETHICS ................ 10 9 8 7 6 5 4 3 2 1 0 ________________________ GOVERNMENT REGULATION 10 9 8 7 6 5 4 3 2 1 0 ________________________ COMMUNITY IDENTITY ......... 10 9 8 7 6 5 4 3 2 1 0 ________________________ DIVERSITY/HOMOGENEITY .. 10 9 8 7 6 5 4 3 2 1 0 ________________________ POPULATION + 0 -- ......... 10 9 8 7 6 5 4 3 2 1 0 ________________________ SOCIAL SERVICES .............. 10 9 8 7 6 5 4 3 2 1 0 ________________________ HEALTH CARE ..................... 10 9 8 7 6 5 4 3 2 1 0 ________________________ CRIME / DRUG ABUSE .......... 10 9 8 7 6 5 4 3 2 1 0 ________________________ EDUCATION .......................... 10 9 8 7 6 5 4 3 2 1 0 ________________________ YOUTH PROGRAMS ............. 10 9 8 7 6 5 4 3 2 1 0 ________________________ YOUTH ETHICS ..................... 10 9 8 7 6 5 4 3 2 1 0 ________________________ IMMIGRATION [IL]Legal ......... 10 9 8 7 6 5 4 3 2 1 0 ________________________ TERRORISM: Dom/For ............ 10 9 8 7 6 5 4 3 2 1 0 ________________________ POLITICS ............................... 10 9 8 7 6 5 4 3 2 1 0 ________________________ TIME MANAGEMENT .............. 10 9 8 7 6 5 4 3 2 1 0 ________________________ BANKRUPTCY ...................... 10 9 8 7 6 5 4 3 2 1 0 ________________________ NATURAL HABITAT ............. 10 9 8 7 6 5 4 3 2 1 0 ________________________ ENVIRONMENT PROTECTION 10 9 8 7 6 5 4 3 2 1 0 ________________________ NATURAL RESOURCES ...... 10 9 8 7 6 5 4 3 2 1 0 ________________________ DEPLETION ........................... 10 9 8 7 6 5 4 3 2 1 0 ________________________ NATURAL DISASTERS ......... 10 9 8 7 6 5 4 3 2 1 0 ________________________ GASOLINE/DIESEL FUEL ...... 10 9 8 7 6 5 4 3 2 1 0 ________________________ Other __________________ 10 9 8 7 6 5 4 3 2 1 0 ________________________ Local C of C member? Y N X (when): _______ Other Orgs: ____________________________________ Local business/community professionals you know personally? 0 1-5 6-10 11-15 16-25 >25 How many do you see at least: Weekly [W]? Monthly [M]? 0 1-5 6-10 11-15 16-25 >25 WHY? or WHY NOT? __________________________________________________________________ Who do you consider to be the most influential and respected leaders in this community? ____________________ ____________________ _____________________ ______________________ In what community do you live? ____________________________________ Resp: EX VG Gd Acc Fr Pr Level of Interest & Concern in community issues? 10 __ 9 __ 8 __ 7 __ 6 __ 5 __ 4 __ 3 __ 2 __ 1 __ 0 __ Response to Rotary Business survey concern: Ex __ VG ___ Gd ___ Acc ___ Fr ___ Pr ___ Vers: 1005E
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on behalf and in support of the
GIFT OF SIGHT FOUNDATION --
Rotary District 7620 by supporters of The ROTARY FOUNDATION of ROTARY INTERNATIONAL.