Form Approved
OMB No. 0920-0982
Expiration date: 09/30/2015
Home Tap Water Questionnaire
(interviewer-administered at telephone recruitment)
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 0920-0982.
Participant ID:
Date:
TO DETERMINE IF YOU NEED TO BRING A HOME WATER SAMPLE WITH YOU TO YOUR CLINIC VISIT, I AM GOING TO ASK YOU A FEW QUESTIONS:
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
Do you have a water softener in your home/apartment?
YES……………....................................…………………………………………….1
NO……………………………………….......................................…………………2
REFUSED………………………………………………..........................................7
DON’T KNOW…………………………………………….......................................9
If YES:
2.1) Is your kitchen/drinking water softened?
YES……………....................................…………………………………………….1
NO……………………………………….......................................…………………2
REFUSED………………………………………………..........................................7
DON’T KNOW…………………………………………….......................................9
Do you have a water filtration system in your home/apartment?
YES……………....................................…………………………………………….1
NO……………………………………….......................................…………………2
REFUSED………………………………………………..........................................7
DON’T KNOW…………………………………………….......................................9
If YES:
3.1) Is it a reverse osmosis system?
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 2.1 or 3.1 WE NEED A WATER SAMPLE. PROVIDE THE FOLLOWING BRIEF EXPLANATION:
“We need you to bring us a small sample of your home tap water. Please bring ½ cup water in a clean container with you to your clinic visit. The container can be made of plastic or glass. Do you have any questions?”
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| File Title | Home Tap Water Questionnaire |
| Author | Dearman, Tiffany D. (CDC/ONDIEH/NCCDPHP) |
| File Modified | 0000-00-00 |
| File Created | 2021-01-28 |