Uncle Jim's JavaScript Examples

ON-LINE SURVEY

This is an advanced survey form I created for the local County Sheriff's Office.



If you would like to complete the survey, please click Yes. If you do not wish to submit a survey at this time, please click No. (This will automatically close this window.)Thank You.

Choose One:
Yes
No (This will close this window)

Please answer the following questions by filling out the below information and clicking Submit when you are done. Thank you.

This survey is from:
Business
Residence


(Optional) Gender:
Male
Female

(Optional) Race:
Caucasian
African/American
Hispanic
Other

(Optional) Age:
Under 18
18 to 25
26 to 35
36 to 50
51 to 64
65 +


Do you reside within unincorporated Brevard County?
Yes
No.


If Yes, What neighborhood?.



Have you had any contact with a Deputy of our agency within the last 12 months?
Yes
No.


Please provide us with details regarding this contact:

During this contact, were you the:
Victim
Witness
Suspect

Was the Deputy professional?
Yes
No

Were you treated fairly?
Yes
No

Did the Deputy handle the situation appropriately?
Yes
No

Was the situation handled to your satisfaction?
Yes
No


Approximately how many time in the past 10 years have you (or your family/business) requested service from the Brevard County Sheriffs Office?

None
1 to 5
6 to 10
11 to 30
31 to 50
Over 50


Please rate the Brevard County Sheriffs Office in the following categories:

a. Responding to the community's overall law enforcement needs:
Bad
Poor
Average
Good
Excellent

b. Responsiveness to community drug activity complaints:
Bad
Poor
Average
Good
Excellent

c. Addressing traffic concerns (speeding, acccidents, parking, DUI):
Bad
Poor
Average
Good
Excellent

d. Crime Prevention efforts (Neighborhood Watch, Business Watch, Personal Safety, Fraud and Scams):
Bad
Poor
Average
Good
Excellent

e. Handling community crime concerns:
Bad
Poor
Average
Good
Excellent

f. Treatment of people with courtesy, respect and compassion:
Bad
Poor
Average
Good
Excellent

g. Addressing quality of life issues in the community:
Bad
Poor
Average
Good
Excellent



h. How would you describe your feeling of safety and security in your neighborhood:
Bad
Poor
Average
Good
Excellent



What do you believe are the three most significant concerns in Brevard County that we should concentrate on improving:
1.
2.
3.

Please provide any comments or suggestions on how we can improve the quality of our services:



Occasionally, we may need clarification on comments. Please supply your email address in the event we need clarification. (optional)


Thank you for participating in this survey. Click Here to Close This Window
END OF SURVEY -- THANK YOU FOR YOUR TIME