Residential Action Checklist, Fall 2022

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My Committment

Fill this out to substantiate your commitment to reducing your energy use and lowering your overall carbon footprint.

Checkboxes

• First Choice
• Second Choice
• Third Choice

Black Grey Pattern Shoes

Excellent	Good	Average	Poor
ExcellentBlack Grey Pattern Shoes Excellent	GoodBlack Grey Pattern Shoes Good	AverageBlack Grey Pattern Shoes Average	PoorBlack Grey Pattern Shoes Poor

Long Sleeves T-Shirt

Excellent	Good	Average	Poor
ExcellentBlack Grey Pattern Shoes Excellent	GoodBlack Grey Pattern Shoes Good	AverageBlack Grey Pattern Shoes Average	PoorBlack Grey Pattern Shoes Poor

Sneakers

Excellent	Good	Average	Poor
ExcellentBlack Grey Pattern Shoes Excellent	GoodBlack Grey Pattern Shoes Good	AverageBlack Grey Pattern Shoes Average	PoorBlack Grey Pattern Shoes Poor

Rate Your Overall Experience At Our Store

Rate 1 out of 5Rate 2 out of 5Rate 3 out of 5Rate 4 out of 5Rate 5 out of 5

Please Share Your Feedback

Would You Love To Shop Again From Us?

• Yes
• No
• May be

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Likert Scale

	Strongly Disagree	Disagree	Neutral	Agree	Strongly Agree
Item #1	Strongly DisagreeItem #1 Strongly Disagree	DisagreeItem #1 Disagree	NeutralItem #1 Neutral	AgreeItem #1 Agree	Strongly AgreeItem #1 Strongly Agree
Item #2	Strongly DisagreeItem #2 Strongly Disagree	DisagreeItem #2 Disagree	NeutralItem #2 Neutral	AgreeItem #2 Agree	Strongly AgreeItem #2 Strongly Agree
Item #3	Strongly DisagreeItem #3 Strongly Disagree	DisagreeItem #3 Disagree	NeutralItem #3 Neutral	AgreeItem #3 Agree	Strongly AgreeItem #3 Strongly Agree
	Strongly DisagreeStrongly Disagree	DisagreeDisagree	NeutralNeutral	AgreeAgree	Strongly AgreeStrongly Agree
	Strongly DisagreeStrongly Disagree	DisagreeDisagree	NeutralNeutral	AgreeAgree	Strongly AgreeStrongly Agree

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