1. Are you aware that the Federal Government plans to situate a radioactive waste dump in your region?

Yes
No

2. In an international broadcast, Senator Nick Minchin stated that your community was part of an exhaustive consultative process. Do you agree?

Yes
No

If so, how were you consulted?    

3. Have you been educated about the danger of being exposed to radiation?

Yes
No

4. Do you understand what is meant by Category S waste?

Yes
No

5. National radioactive waste will be transported from throughout Australia. Most will travel over 2000 km. Are you concerned about exposure to radiation resulting from transport accidents?

Yes
No

6. Do you believe the Government when it says that the National dump will not turn into an International dump?

Yes
No

7. Do you want the Nuclear Industry to expand in Australia ?

Yes
No

8. Do you want your community to be Nuclear Free?

Yes
No

9. Do you want the dump to go ahead?

Yes
No

10. Name of your township:    

Name and Address (Optional):    

Additional comments: