Community Survey

Name *

First Name

Last Name

Phone *

(###)

###

####

Date of Birth

MM

DD

YYYY

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

How satisfied are you with the current Australian government? (Please tick one)

Very Unsatisfied

Unsatisfied

Unsure

Satisfied

Very Satisfied

Jobs and Wages

1

2

3

4

5

Health

1

2

3

4

5

Climate Change and Clean Energy

1

2

3

4

5

Housing

1

2

3

4

5

Education and Training

1

2

3

4

5

Cost of Living

1

2

3

4

5

Child Care

1

2

3

4

5

Social Services

1

2

3

4

5

Immigration

1

2

3

4

5

Which party do you usually support? (Please tick one)

Labor

Liberal

Greens

Other

If a Federal Election were being held today which party would receive your first preference? (Please tick one)

Labor

Liberal

Greens

Other