1.) How long do you use you heating/ air conditioning system on a daily basis?
☐ Less than an hour
☐ 1-3 hours
☐ 3-6 hours
☐ 6-10 hours
☐ 10+ hours
☐ _________________ (if you answered more than 10 hours)
2.) How many hours do you use the computer daily?
☐ Less than 2 hours
☐ 2-4 hours
☐ 4-6 hours
☐ 6-8 hours
☐ 8+ hours
☐ _________________ (if you answered more than 8 hours)
3.) Are you a commuter?
☐ Yes
☐ No
4.) How far is your commute? (if you answered yes to #3)
☐ 1-5 miles
☐ 5-10 miles
☐ 10-15 miles
☐ 15-20 miles
☐ 20+ miles
______________________ (if you answered more than 20 miles)
5.) How do you get to school? (if you answered yes to #3)
☐ Bus
☐ Train
☐ Car
6.) If you don’t commute, how often do you use public transportation? (cars, buses, trolleys, subway etc.)
☐ 0-4 times daily
☐ 4-6 times daily
☐ 6+ times daily
___________________ ( if you answered more than 6 times)
7.) How long do you watch T.V daily?
☐ Less than 1 hour
☐ 1-3 hours
☐ 4-5 hours
☐ 5+ hours
☐ _________________ (if you answered more than 5 hours)
8.) What kind of light bulb do you use? (in dorms, in apartments etc.)
☐ Fluorescent
☐Incandescent
☐ LED
9.) How much time do you spend in the shower?
☐ Less than 5 minutes
☐ 5-10 minutes
☐ 10-15 minutes
☐ 15-20 minutes
☐ 20-30 minutes
☐ ___________________ (if more than 30 minutes)
10.) Do you use cold water or hot water when you shower?
☐ Cold
☐ Hot
11.) How long does it take to charge your cellular phone?
☐1-2 hours
☐ 2-3 hours
☐ 3-4 hours
12.) Do you leave your phone connected to the charger even after its charged?
☐ Yes
☐ No
____________ (if you answered yes, how long? )
13.) If you smoke, how often do you smoke?
☐ N/A ( Not applicable)
☐ Less than 5 cigarettes daily
☐ 5-10 cigarettes daily
☐ 10-15 cigarettes daily
☐ 1 pack (20 cigarettes)
☐ 1 pack +
____________________ (if you answered more than a pack)
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