Quality of Life Action Survey

First Name: *

Last Name: *

Your Street Address: *

City, State Zip Code: *

Email Address: *

Phone Number: *

Instructions:

Please fill out the issue(s) you may have.Please provide as exact and concise information as possible. Please remember to fill-out all of the information above so we can stay in touch with you.

Graffiti cleanup needed:

Yes

If the answer is yes, please specify location/Floor/Description:

Air/Noise Pollution conditions:

Yes

If the answer is yes, please specify location:

Inspection needed:

Business operating in a residential home

Illegal Single Room Occupancy being conducted

Please specify location:

MTA. Bus Issue. Bus frequency issue, stop issue, other:

Yes

If yes please specify:

Overnight truck or commercial vehicle parking on a city street:

Yes

If the answer is yes, please specify location/vehicle description:

Catch basin- Clogged/Broken. NE/NW/SE/SW corner of location (s):

Tree issue, stump removal or tree pruning request locations (s):

MillionTreesNYC request, check Y/N if you would like a tree planted in front of your home:

Yes

Fire hydrant:

leaking

broken

Please specify fire hydrant location:

Illegal dumping- Vacant lot/Public area:

Please specify

Abandoned and unsecured property:

Please specify location/description of conditions.

Troublesome nightlife hotspot:

Please specify location and existing conditions.

Park/Playground concerns:

Please specify location/description.

Pothole/Street Collapse:

Please specify location.

Street light (s) –Out/Damaged/Wires exposed.:

Please specify location (s)

Street flooding/Ponding conditions:

Please specify location.

Street resurfacing needed:

Please specify location (street and between cross street and cross street)

Traffi c controls needed- Light/All-Way Stop:

Please specify location

Traffic sign replacement needed.:

Please specify location.

Police attention needed:

Please specify description/Location/Day(s) & Time (we will forward this information to the local police precinct)

I have another issue which hasn’t been mentioned!:

Please provide a description of the issue you are facing and what we can do to assist you.

“There should be a law for that!”:

In the past, I have been able to introduce legislation based on the suggestions you have provided me. Please include a detailed description of a particular issue and how you believe we can assist you at the State level:

Terms of Participation: *

I'm over 13.

I've read the Terms of Participation.

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