Attachment H
Example Questionnaire
Form Approved OMB No. 0920-XXXX Exp. Date xx/xx/20xx
Sample questionnaire introduction for investigation that includes collecting questionnaire data and environmental samples:
Thank you for taking our investigation. The questions in our questionnaire should take less than thirty five minutes. After that, we will be offering free {FILL IN TYPE(S)} = [FOR ENVIRONMENTAL-air, soil, water, foods testing] Once we are done with this investigation, you will be given a copy of the testing results. Generally, we are able to get results to you within {FILL IN ADJUSTED TIME FRAME OR INSERT 4 – 8 WEEKS}.
Sample questionnaire introduction for investigation that includes collecting questionnaire data and biologic specimens:
Thank you for taking part in our investigation. The questions in our questionnaire should take less than thirty five minutes. After that, we will be offering free {FILL IN TYPE(S)} = [FOR BIOLOGIC-blood, urine, hair, nails, other testing for you]. Once we are done with this investigation, you will be given a copy and details of your test results. Generally, we are able to get results to you within {FILL IN ADJUSTED TIME FRAME OR INSERT 4 – 8 WEEKS}.
CDC estimates the average public reporting burden for this collection of information as 35 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Ga. 30333; ATTN: PRA (0920-xxxx).
Interviewer
Name: ________________________ Interview Location:
_______________________________ Participant
ID: _______________________ Date
of Interview: _________/________/______ (month/day/year)
Phone (____) _________________________
Participant
Name: ________________________________________________
Mailing Address: ________________________________________________
City: _____________________ Zip code: ________________
Physical Address: ________________________________________________
City: _____________________ Zip code: ________________
GPS (at well head): _____________________
Sociodemographics
How old are you (in years)? ________
What is your sex?
Male
Female
Refused
Please tell us how many people in your household (including yourself) are in the following age categories:
Age Category |
How many in the household |
Less than 2 years old |
|
2 years-17 years old |
|
18 years-64 years old |
|
More than 64 years old |
|
What is the highest grade of school that you completed?
Did not graduate high school
High School Graduate
Some College
Associates Degree
Bachelors Degree
Post Graduate Degree
Refused
Before taxes, what is your total yearly household income?
Less than $10,000
$10,000-24,999
$25,000-49,999
$50,000-74,999
$75,000-99,999
$100,00-150,000
Greater than $150,000
Refused
What is your ethnicity?
Hispanic or Latino
Not Hispanic or Latino
What is your race?
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Refused
Household water source
How long have you lived in your home?
________________ (months/years)
Refused
How would you describe the physical condition of your well (including your well pump and well casing, or the tube that is placed in the drilled hole to maintain the well opening)?
Good condition
Minor problems
Deteriorating
Don’t know
Refused
How deep is your well? ______________ ft Don’t know Refused
How old is your well? ______________ ft Don’t know Refused
During the past year, have you ever had a problem with your well providing insufficient water for household uses?
Yes
No
Don’t know
Refused
During the past year, have you ever had any concerns with the quality of your well water?
Yes Describe: ____________________________________________________
No
Don’t know
Refused
Household water use
How many 8 oz. glasses of water (including water for making other beverages, such as coffee or orange juice) have you drunk from your well in the last 24 hours?: ______ glasses
In the past week, where do you usually get your drinking and cooking water? [Rank order, 1=most and 4=least]
Your Well: ___________
Bottled Water: ___________
Water from a Filter Jug: ___________
Other sources: ___________ Specify: ___________________________
When at home, what is the main reason that you drink water from sources other than your well?
Bad taste
Bad smell
Bad appearance
Convenience
I don’t, I only use tap water
Other, please specify: _______________________________
No reason
When you cook with water, how often do you use the tap water from your private well? (e.g., soups, pasta, rice, etc.)?
Always
Most of the time
Half of the time
Infrequently
Never
Do you use any of the following water filters in your home? Check all that apply.
Jug or pitcher filter
Faucet-mounted filter
Counter-top filter
Under-sink filter
Reverse-osmosis system
Refrigerator filter
Whole house system (a single system that treats all the water in your house)
Other (specify):
You do not use a water filter in your home
19. If you use a filter in your home, do you regularly replace and maintain the filters?
Yes
No
Don’t know
Refused
Exposure information
20. What kind of work do you do (for example, registered nurse, computer specialist, cashier, auto
mechanic, etc.)? ______________________________________________________________________________
21.What kind of business or industry do you work in (for example, hospital, elementary school,
laboratory, clothing manufacturing, restaurant, etc.)? ______________________________________________________________________________
22.Have you eaten or drunk any of the following in the past 3 days?
a. Fish (including fresh fish, fish sticks, canned tuna fish, fish sandwiches, etc.) |
Yes |
No |
b. Shellfish (shrimp, oyster, crab, etc) |
Yes |
No |
c. Rice |
Yes |
No |
d. Homeopathic, home, folk, or natural remedies |
Yes |
No |
23. Have you used any pesticides including animal repellant, fungicide, herbicide, insecticide, etc. to get rid of insects, rodents, weeds, or other pests in the past 3 days?
Yes
No
22a. If yes, was that done inside your home, outside your home, or both?
Inside
Outside
Both
24. What hobbies, excluding sports, (for example, ceramics, jewelry making, painting), do you have? _____________________________________________________________________________
25. Do you smoke?
Yes
No
26. Has anyone smoked tobacco (such as cigarettes) in the home in the last 3 days?
Yes
No
Perceptions and practices that could impact an individual’s exposure level
27. In your opinion, how would you rate the following characteristics of your well water?
Taste: Very good Good Neutral Bad Really bad
Smell: Very good Good Neutral Bad Really bad
Appearance: Very good Good Neutral Bad Really bad
Safety: Very good Good Neutral Bad Really bad
28. When was the last time your well water was tested?
Within the last year
More than one year ago but less than five years ago
More than five years ago
My well has never been tested Go to Question 36.
Don’t know Go to Question 36.
29. The last time your well water was tested, what did you test for? Check all that apply.
Arsenic
Bacteria/germs
Chloride
Color
Copper
Fluoride
Hardness
Iron
Lead
Manganese
Nitrates
Pesticides
pH
Radionuclides (Uranium, Radon, Radium)
Sulfate
Total dissolved solids
Volatile Organic Compounds (VOCs)
Other (specify):
Don’t know
30. Have you ever received the results of the testing?
Yes
No Skip to 38.
31. . If yes, what did the results tell you about your well water quality?:____________________
32. If yes, what actions did you take as a result of receiving your well results?:________________
33. I should test my well to make sure that my water is safe.
Strongly Agree
Agree
Disagree
Strongly Disagree
34. I would be more likely to test my well if I received a public notice from the county/state about water contamination in my neighborhood.
Strongly Agree
Agree
Disagree
Strongly Disagree
35. I would be more likely to test my well if I knew what contaminants to test for.
Strongly Agree
Agree
Disagree
Strongly Disagree
File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
File Modified | 0000-00-00 |
File Created | 2021-01-14 |