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[SCHOOL NAME] is very interested in your opinion regarding [ISSUE]. Please take our brief survey so we can get your candid feedback on your familiarity with it, its importance to you, and what actions may be appropriate in response. Your responses will remain anonymous.
1. Please tell us how important [ISSUE] is to you:
2. Please tell us how serious a problem you view [ISSUE] is on our campus:
3. We would like your feedback on some possible response actions to [ISSUE]. For each one, please tell us how strongly you favor or oppose it:
  Strongly favorSomewhat favorNeither favor nor opposeSomewhat opposeStrongly oppose
[RESPONSE ACTION 1]
[RESPONSE ACTION 2]
[RESPONSE ACTION 3]
[RESPONSE ACTION 4]
[RESPONSE ACTION 5]
4. How informed would you say you are on [ISSUE]?
5. How satisfied are you with each of the following campus and community groups in providing information on [ISSUE]?
  Very satisfiedSomewhat satisfiedNeither satisfied nor dissatisfiedSomewhat dissatisfiedVery dissatisfiedNot Sure/Don't Know
Administration
Dean of Students
Dean of School
Faculty
School Web Site
Student Government
Fraternity/Sorority Groups
Campus Newspaper
Campus Radio/TV Stations
Local Newspaper
Local Radio Stations
Local Television Stations
6. Please tell us which campus and community groups you think should be providing information about [ISSUE]: Please select all that apply
7. How interested are you in learning more about [ISSUE]?
8. Please share any questions, thoughts or possible solutions you may have about [ISSUE]: