Paper-based Questionaire

Epidemiologic Study of Health Effects Associated with Low Pressure Events in Drinking Water Distribution Systems

OMB Appendix G Household survey (paper version)

Paper-Based Questionnaire (Pilot and Mult-site)

OMB: 0920-0960

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									Form Approved	
									0920-xxxx	
									Exp xx/xx/xxxx	
											
											

CDC Water and Health Study

Instructions

An adult (18 years old or over) should
fill out this survey. If there are children
less than 18 in the house, the adult
should fill out the survey for them.
Participation is voluntary. Return of
a completed survey indicates your
consent to participate. For more
information, please see the enclosed
brochure.

Public reporting burden of this collection of information is
estimated to average 12 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, Georgia 30333; ATTN: PRA (0920-xxxx).

Section 1	 Household Water Use
In this first section, we’d like to ask some general questions about your household water use.
By “tap water,” we mean drinking water supplied by your water company.	

1 Please mark all of the ways that you and the

o 
Drinking
o 
Mixing cold drinks
o Making hot drinks
o Making ice
o Rinsing produce
o Cooking
o Mixing infant formula
o Washing dishes
o Brushing teeth
o Washing hands
o Bathing/showering
o Contact lens care
o Watering plants or lawn

2 At home, what type of water do you and

o 
	
Tap water, treated in the home (for example,
	 boiled or filtered)		
o 
	
Tap water, treated with a water softener only	
o 
	
Tap water, not treated in the home
o 
	
Tap water, not sure how it is treated		
o 
	
Commercially bottled water	
o 
	
Other (Please specify________________________)	
						

3 Does your home have a private well?

o Yes
o No
o Don’t know

4 Do you have a water softener in your home?

o Yes
o No
o Don’t know

5 What water filters are used in your home?

o No water filter used
o 
Water pitcher with filter
o 
Refrigerator dispenser with filter
o 
Filter on the faucet
o 
Filter under the sink
o 
	
Other (Please specify________________________)	
o Don’t know

people in your household have used tap water
in the last 30 days. (check all that apply)

other members of your household drink
most often? (check only one)

(check all that apply)

o Feeding/watering 	
	animals
o Filling wading or 	
	 baby pool
o Filling pool or hot tub
o Indoor or outdoor 	
	fountain
o Vaporizer or
	humidifier
o Nebulizer or CPAP
o Nasal/sinus
	 irrigation or Neti pot

Go on to next page

Section 2	

Your Home	

Please answer the following general questions about your home.	

6 Which of the following best describes where

o 
House
o 
Apartment or condominium	
o 
Mobile Home
o 
Other (please specify______________________)	

7 What pets do you have in your home or yard?

o 
No pets
o 
Hamster, gerbil, or mouse
o 
Bird				
o 
Adult dog			
o 
Puppy
o 
Reptile or amphibian (e.g. turtle, snake, iguana, 		
	 frog, chameleon, salamander)	
o 
Adult cat			
o 
Kitten
o 
Other	 (please specify______________________)	

8 Are there any livestock or animal enclosures

o 
No livestock or animal enclosures
o 
Cattle or feedlots
o 
Poultry or poultry houses
o 
Pigs
o 
Horses
o 
Other livestock/animal enclosures
	 (please specify______________________)
	

you live? (check only one)

(check all that apply)

located within 50 yards of your household?

(check all that apply)

Go on to next page

Section 3	Recent Water Service	
In this section, we are asking about your recent water service. Please refer to the label on the front of
this booklet or the enclosed calendar for the dates of the 3-week period.	 	

9 At any time during the 3-week period on the
label,

	Did anyone in your home notice low
water pressure? (For example, you turned
on the faucet and the water didn’t come
out as much as usual or the pipes made a
sputtering noise.)	

o 
Yes
o 
No
o 
Don’t know
	

	Did you completely lose water service?
(For example, you turned on the faucet
and nothing came out.)	

o 
Yes
o 
No
o 
Don’t know
	

	Did anyone notice a change in the odor,
taste, or color of tap water at home?
(check all that apply)	

o 
Change in odor
o 
Change in taste
o 
Change in color
o 
Did not notice any changes
	

	Were you told to boil your water before
drinking it? (For example, on the news, by a
phone call, or on a door hanger)

o 
Yes
o 
No
o 
Don’t know

If YES, what did you use for
drinking water during that time?
o	We only drank bottled water.
o	We always boiled our tap
water before we drank it.
o	We sometimes boiled our
tap water before we drank it.
o	We usually drank our tap
water without boiling it first.

Go on to next page

Section 4	
10

People in Your Household

How many people, including you, live in your household? Do not include short-term visitors.	
Please enter number in box. 	

	

People

The rest of the survey asks about the individual people in your household. Please do not include
short-term visitors.
To help keep the columns straight, please identify each person with initials. These do not have to be
their real initials. Please keep the same order on the next pages. If there are more than 6 people in
your household, please list yourself, the two oldest, and the 3 youngest. If two individuals have the
same initials, different initials should be used to avoid confusion.
You may need to ask the other household members for some answers. If you cannot ask, please give
your best guess.
	Person 1	
(	 yourself)
11

Person 2	

Person 3	

Person 4	

Person 5	

Person 6

Person’s initials					
					

12

Age (in years)

(If unsure of the
exact age, please
give your best guess.)									
Circle Male or Female
13

Sex

	
Male	Male	Male	Male	Male	Male
	
Female	Female	Female	Female	Female	Female

Go on to next page

Section
5	D
Section
4 rinking Water Use
	Person 1	
(	 yourself)

Person 2	

Person 3	

Person 4	

Person 5	

Person 6

Person’s initials
(copy from Question 11)
14

What is each person’s main
source of drinking water at
home?
	
Water from the tap, not
filtered

Put an X in 1 box for each person.

Water from the tap, filtered
Bottled water

Other (please specify) 	
________________________________________________________		
	________________________________________________________	
In the next 2 questions, we are asking about drinking water from your water utility, or “tap water,”
that comes from your house. For these questions, it does not matter if you filter the water.
15

16

On average, about how
many 8 ounce glasses of
your home tap water does
each person drink per day?
Include water from home
that you drink at another
location, such as work,
school, or sports activities.	
On average, about how
many 8 ounce glasses of
drinks mixed with your
home tap water, such as
Kool-Aid, instant iced tea,
or watered-down juice,
does each person drink per
day? Do not include hot
beverages, like brewed
coffee or tea.			
		

Glasses	 Glasses	Glasses	Glasses	Glasses	Glasses

Glasses	 Glasses	Glasses	Glasses	Glasses	Glasses

Go on to next page

Section 6	Recent Activities
In this section, we are interested in recent activities you and your household members did during
the 3-week period. Please refer to the label on the front of this booklet or the enclosed calendar for
the dates of your 3-week period.										
											
	Person 1	
(	 yourself)

Person 2	

Person 3	

Person 4	

Person 5	

Person 6

Person’s initials (copy from
Question 11)	
17

During the 3-week period,
did anyone

Circle Yes or No for each person.

 Swim or wade in a
lake, river, stream or
ocean?	

	
Yes	Yes	Yes	Yes	Yes	Yes
	
No	No	No	No	No	No

 Swim in a pool?

	
Yes	Yes	Yes	Yes	Yes	Yes
	
No	No	No	No	No	No

 Swallow or drink any
water directly from a
spring, lake, pond, stream,
or river?

	
Yes	Yes	Yes	Yes	Yes	Yes
	
No	No	No	No	No	No

 Drink any water from a
well?

	
Yes	Yes	Yes	Yes	Yes	Yes
	
No	No	No	No	No	No

 Go hiking or camping?	
		

	
Yes	Yes	Yes	Yes	Yes	Yes
	
No	No	No	No	No	No

 Attend, work, or volunteer
in a day care?

	
Yes	Yes	Yes	Yes	Yes	Yes
	
No	No	No	No	No	No

 Visit a petting zoo or farm
with animals?

	
Yes	Yes	Yes	Yes	Yes	Yes
	
No	No	No	No	No	No

 Travel outside of the
United States?	

	
Yes	Yes	Yes	Yes	Yes	Yes
	
No	No	No	No	No	No
Enter number of nights away from home.

 Spend any nights away
from home?
Go on to next page

Section 7	 Stomach Problems			
Please refer to the label on the front of this booklet or the enclosed calendar for the dates of the
3-week period. In this section, we are asking about new stomach problems that started during
the 3-week period (“new onset”), not problems that you normally have.
	Person 1	
(	 yourself)

Person 2	

Person 3	

Person 4	

Person 5	

Person 6

Person’s initials (copy from
Question 11)
18

During the 3-week period,
did anyone have a new
onset of any of the following
stomach problems?	

Circle Yes or No for each person.				

	Vomiting?

	
Yes	Yes	Yes	Yes	Yes	Yes
	
No	No	No	No	No	No

	Nausea?

	
Yes	Yes	Yes	Yes	Yes	Yes
	
No	No	No	No	No	No

	Diarrhea? (defined as 3
or 	more loose stools or
bowel movements in any
24-hour period)

	
Yes	Yes	Yes	Yes	Yes	Yes
	
No	No	No	No	No	No

	Stomach cramps?

	
Yes	Yes	Yes	Yes	Yes	Yes
	
No	No	No	No	No	No

	Did they have a fever
(100oF or higher) at the
same time as stomach
problems?

	
Yes	Yes	Yes	Yes	Yes	Yes
	
No	No	No	No	No	No

If anyone had ANY stomach problems in question 18, please answer questions 19 and 20.
Write a number of days in box.
19

20

How many days did the
stomach problems last?
				
When did the stomach
problems start? (MM/DD/YY)	
__/__/__	
__/__/__	__/__/__	__/__/__	__/__/__	__/__/__
If you are unsure of the exact
date, please give your best
guess.

Go on to next page

Section 8	Colds and Flu	
Please refer to the label on the front of this booklet or the enclosed calendar for the dates of the
3-week period. In this section, we are asking about new cold and flu symptoms that started during
the 3-week period (“new onset”), not symptoms that you normally have.
	Person 1	
(	 yourself)

Person 2	

Person 3	

Person 4	

Person 5	

Person 6

Person’s initials (copy from
Question 11)		
21

During the 3-week period,
did anyone have a new onset
of any of the following cold/
flu symptoms?

Circle Yes or No for each person.				

	Cough?

	
Yes	Yes	Yes	Yes	Yes	Yes
	
No	No	No	No	No	No

	Runny nose?

	
Yes	Yes	Yes	Yes	Yes	Yes
	
No	No	No	No	No	No

	Muscle/body aches?

	
Yes	Yes	Yes	Yes	Yes	Yes
	
No	No	No	No	No	No

	Difficulty breathing?

	
Yes	Yes	Yes	Yes	Yes	Yes
	
No	No	No	No	No	No

	Did they have a fever
(100oF or higher) at the
same time as the cold or
flu symptoms?

	
Yes	Yes	Yes	Yes	Yes	Yes
	
No	No	No	No	No	No

If anyone had ANY cold/flu symptoms in question 21, please answer questions 22 and 23.
Write a number of days in box.
22

How many days did the cold/
flu symptoms last?

23

When did the cold/flu
symptoms start? (MM/DD/YY)
If you are unsure of the exact
date, please give your best
guess.

__/__/__	
__/__/__	__/__/__	__/__/__	__/__/__	__/__/__

If you answered Yes to any stomach problems or cold or flu symptoms in section 7 or
section 8, please go on to section 9, Illness Details on the next page. If no one in your
household had any stomach problems, cold or flu symptoms please skip to section 10.

Section 9	Illness Details
Please complete the section only if you answered Yes to any symptoms in section 7 or
section 8. If no one had stomach problems, cold or flu symptoms in the 3-week period,
you can skip to section 10 on the next page. 	
These questions are asking about how illnesses during the 3-week period affected you.		
	Person 1	
(	 yourself)

Person 2	

Person 3	

Person 4	

Person 5	

Person 6

Person’s initials (copy from
Question 11)			
				
Write a number of days in box.
24

How many days of school
or work did each person
miss because of stomach
problems, cold or flu?
(enter number of days
missed, enter 0 if no
school or work missed)	
			

Circle Yes or No for each person.				

25

Did anyone see a healthcare
provider for stomach
problems, cold, or flu
symptoms?

	
Yes	Yes	Yes	Yes	Yes	Yes
	
No	No	No	No	No	No

26

Did a healthcare provider
ask anyone to submit a
stool sample for testing?

	
Yes	Yes	Yes	Yes	Yes	Yes
	
No	No	No	No	No	No

27

Was anyone admitted to the
hospital for at least one day
as a result of this illness?

	
Yes	Yes	Yes	Yes	Yes	Yes
	
No	No	No	No	No	No

Go on to next page

Section 10	More About People in Your Household	

Person’s initials (copy from
Question 11)
		
28

Does any household member
have chronic diarrhea or
vomiting (because of a health
condition like Irritable Bowel
Syndrome, Crohn’s disease,
Ulcerative colitis, etc. or a
medication side effect?)

29

Does any household member
have a chronic respiratory
condition (such as asthma,
emphysema, COPD, etc.)

	Person 1	
(	 yourself)

Person 2	

Person 3	

Person 4	

Person 5	

Person 6

Circle Yes or No for each person.	

	
Yes	Yes	Yes	Yes	Yes	Yes
	
No	No	No	No	No	No

	
	
Yes	Yes	Yes	Yes	Yes	Yes
	
No	No	No	No	No	No
	

Section 11	Demographic Information	
The following questions are optional, but providing answers will help us better understand how well our
study is describing the experience in your community.
	Person 1	
(	 yourself)
30

Person 2	

Person 3	

Person 4	

Person 6

Is each person of Hispanic or
	
Yes	Yes	Yes	Yes	Yes	Yes
Latino ethnicity? (Please answer 	
No	No	No	No	No	No

for yourself and Persons 2-6)
31

Person 5	

What is each person’s race?
Mark one or more boxes.

(Please answer for yourself and
Persons 2-6)

American Indian or Alaska Native
Asian	
Black or African American
Native Hawaiian or
other Pacific Islander	
White

Check all that apply.				

Comments
Are there any additional comments or information that you would like to provide?			
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________		

We really appreciate your participation
in this important study. Please fold this
survey in half lengthwise, place it in the
enclosed postage-paid envelope and
put it in any U.S. Mail box.			

						
Please mail to:
CDC
Mailstop C-09	
Attention: Water and Health Study
1600 Clifton Rd. NE
Atlanta, GA 30333

Fold along dotted line and place in envelope.

This concludes the CDC Water and
Health Study. Thank you!


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