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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?
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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!
| File Type | application/pdf |
| File Modified | 2013-03-18 |
| File Created | 2013-03-18 |