Specifications

Consumer Survey
1. How did you hear about this electronics collection event?
 TV Ad  Radio  Flyer
 Newspaper Ad  Friend/word of mouth  Other ________________
2. Why did you come here today to recycle your electronic product(s)? (Choose up to two)
 I had no other place to take this product
 This was a convenient way to get rid of my old electronics
 Other (please specify): _______________________________________________________________
3. How far did you travel today to recycle your electronics (give your best estimate)? ________ miles
4. What items did you bring in today?
Item How
many?
Product
Brand
How old is
the item?
(in years)
Is it
working?
Is it a previously
used or second
hand item?
TV Y N Y N
Computer (CPU) Y N Y N
Computer Monitor Y N Y N
Computer Peripheral:
Mouse
Keyboard
Printer
Scanner
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Other: ______________ Y N Y N
Other: ______________ Y N Y N
5. How many computers and TVs do you have at home? ________
6. Who do you think should pay for the safe recycling and disposal of these electronic products?
(Check no more than 2)
 Customer/user  Government
 Retail store  Other (please specify): ___________________
 Electronics manufacturer
7. Who do you think should operate the program for safe recycling and disposal of electronics?
(Check no more than 2)
 Retail store  Charity
 Electronics manufacturer  Other (please specify): ___________________
 Government
8. If you had to pay to recycle your electronics, when would you prefer to pay?
 When I purchase the item
 When I recycle the item
 Other (please specify): _______________________________________________________________
9. If you had to pay to recycle your electronics, what is the most you would be willing to pay? $_______
10. The electronics you brought in today were used by a
 Residence  Government
 Business  Institution
Thank you for participating in today’s electronics collection event.
(To be filled out by collection event host)
Collection event location (city, state): __________________ Date: ___________
Collection event type (e.g. municipal drop off, retailer): _______________ Participant Number __________