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Platform For Change: Community Feedback Form
The following questions are provided to participants at every Platform for Change Town Hall. The goal is to intentionally de-center the voices of people outside of our community and to center your experiences and observations as a member of this community.
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Email
*
Your email
Demographic Information
Are you a resident of Spokane County?
Yes
No
Clear selection
What is your zip code?
Your answer
Are you experiencing housing insecurity (e.g., your rent/mortgage is late or delinquent, you're currently staying with relatives or a friend, etc.)?
Yes
No
I don't wish to Answer
Clear selection
Select a category below that best describes your age.
17 or Younger
18-25
26-35
36-45
46-55
56-65
66 and over
Clear selection
How would you self-describe your gender? (Check all that apply)
Woman/Female
Gender non-conforming
Intersex
Man/Male
Non-binary
Transgender
Two-spirit
Other
I do not wish to answer
Other:
How would you self-describe your sexual orientation? (Check all that apply.)
Asexual
Bisexual
Gay
Lesbian
Pansexual
Queer
Straight/Heterosexual
I am not sure
Other
I do not wish to answer
Other:
Please select which racial and ethnic category you identify with? (Check all that apply.)
African American/Black
Asian
Latinx (Latino, Hispanic)
Middle Eastern
Native American
Pacific Islander
Southeast Asian
White
Bi-racial (two or more races
Other:
What languages are spoken in your home?
Your answer
Were you born in the United States?
Yes
No
Clear selection
At any point in your life, have you ever been arrested, on probation, on parole, or incarcerated for any length of time?
Yes
No
I do not wish to answer
Clear selection
At any point in your life, has someone in your immediate family ever been arrested, on probation, on parole, or incarcerated for any length of time?
Yes
No
I do not wish to answer
Clear selection
Are you currently experiencing homelessness/houselessness (e.g., couch surfing, living in a motel, living in a car or tent, unsheltered)?
Yes
No
I don't wish to Answer
Clear selection
Community Safety and Wellness Policy
What do we need in our community to keep each other safe and well?
Your answer
What does safety mean to you? What does it look like? Feel like? Sound like? Smell like?
Your answer
What makes Spokane unsafe for our community members? What is negatively affecting the well-being of our community members?
Your answer
What do we want to change so that we can maintain the safety and well-being of our community?
Your answer
If Spokane were safe it would … (finish the sentence)
Your answer
What is already happening in Spokane that keeps us safe and well?
Your answer
What would be possible if Spokane were more safe?
Your answer
What would increase your sense of safety in Spokane?
Your answer
What would it look like to be physically safe in Spokane? Mentally? Emotionally?
Your answer
Who do you turn to for safety?
Your answer
What do you see as your role in creating community safety and wellness?
Your answer
Send me a copy of my responses.
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