Home Tap Water Questionnaire

Form Approved

OMB No. 0920-xxxx

Expiration date: xx/xx/xxxx

Home Tap Water Questionnaire

(interviewer-administered at baseline clinic visit)

Public reporting burden of this collection of information is estimated to average 5 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 Reports Clearance Officer, 1600 Clifton Road, NE, M/S D74, Atlanta, GA 30333, ATTN: PRA 0920-xxxx.

Participant Name:

Participant ID:

Date:

1. What is the source of the tap water in your home/apartment? Is it the city water supply (community water supply); a well or rain cistern; or something else?

CITY/COMMUNITY WATER……………………………………………………….1

A WELL/RAIN CISTERN/SPRING/SOMETHING ELSE……………………….2

REFUSED……………………………………………..……………………………..7

DON’T KNOW………………………………………………….……………………9

2. Do you have a water softener or water filtration system in your home/apartment?

YES……………....................................…………………………………………….1

NO……………………………………….......................................…………………2

REFUSED………………………………………………..........................................7

DON’T KNOW…………………………………………….......................................9

IF PARTICIPANT RESPONDS ‘A WELL/RAIN CISTERN/ SPRING/ SOMETHING ELSE’ TO QUESTION 1 OR ‘YES’ TO QUESTION 2 PROVIDE HIM/HER WITH A HOME WATER COLLECTION KIT AND INSTRUCTIONS FOR COLLECTING AND MAILING THE SAMPLE. ALSO, PROVIDE THE FOLLOWING BRIEF EXPLANATION:

“We need you to send us a small sample of your home tap water. Here is a collection kit that includes a tube that you should fill with water from the tap you use at home most frequently for drinking. After you have filled the tube and closed it please place it in the preaddressed postage paid envelope included in the kit and drop it in the mail. We’d like you to do this in the next day or two. Do you have any questions?”