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2. Name*
3. Email Address*
5. Address*
7. City*
8. State*
9. Zip Code*
11. Phone Number*
12. Date
    Date
16. 1) In the last year [or 2 years], have you seen or heard any information from the City of Portland Natural Gas System relating to pipeline safety?*

    1. Yes
    2. No
18. If yes, What was the source of the information *

    1. Written material (brochure, flyer, handout)
    2. Raido
    3. TV
    4. Newspaper ad or Artical
    5. Face-to-face meeting
    6. Posted information (e.g. on or near pipline)
    7. Other

    Check all that apply

20. If other, please explain.*
22. About how many times did you see information on pipeline safety in the last year?*
24. Have you or has or anyone in your household ever tried to get information about pipeline safety in the last 12 months?*

    1. Yes
    2. No
26. Where did you try? *

    1. Internet
    2. Call
    3. Letter
    4. Visit
    5. Other

    Check all that apply.

28. If other, please explain.*
30. Do you live close to an oil or gas pipeline?*

    1. Yes
    2. No
    3. I do not know.
32. If yes, Where is it (or how close are you to it)?*
34. What would you do in the event you were first to see damage to a pipeline?*

    1. Call 911
    2. Call pipeline company
    3. Flee Area
    4. Nothing (not my responsibility)
    5. Other
36. If other, please explain.
38. Have you ever called the City of Portland Natural Gas System, 911, or anyone else to report suspicious or worrisome activity near a pipeline?*

    1. Yes
    2. No
40. If yes, What did you report:*

    1. Break
    2. Product Release
    3. Digging
    4. Other
42. If other, please explain.
44. Have you or has anyone in your household [or company if a business] ever encountered a damaged pipeline or product released from a pipeline?*

    1. Yes
    2. No
46. If yes, what did you do?
48. Have you ever passed information about pipeline safety to someone else?*

    1. Yes
    2. No
50. If yes, what information and to whom?
52. Has anyone in your household or have nearby neighbors ever had any injuries or damage associated with a pipeline break or spill?*

    1. Yes
    2. No
54. If yes, describe event:
56. Do you agree or disagree that the City of Portland Natural Gas System has been doing a good job of informing people like you about pipeline safety?*

    1. Strongly agree
    2. Agree
    3. Disagree
    4. Strongly disagree
58. If you disagree, why?
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60. 1. Receive an email copy of this form.
61. Email address

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