0920-16NK Att A_CSTEDWA Instrument (Word Version)

Attachment A: CSTEDWA Instrument (Word Version)

Form Approved

OMB No. 0920-0879

Expiration Date 03/31/2018

This assessment is directed to epidemiologists or staff identified by the epidemiologists as subject matter experts, who work in state and local health departments, are acting in their official capacities as government employees, and have responsibility for drinking water issues and private residential wells. This project is funded through a Cooperative Agreement with the Centers for Disease Control and Prevention (CDC). The information obtained from this assessment will provide data needed to inform activities conducted by the Health Studies Branch’s (HSB) Clean Water for Health Program, Division of Environmental Hazards and Health Effects, National Center for Environmental Health, Centers for Disease Control and Prevention. This assessment was developed to identify priority non-infectious issues impacting drinking water, state and local technical assistance needs, and how HSB can best provide technical assistance and support in addressing these priorities.

Council of State and Territorial Epidemiologists (CSTE) Member Assessment of Emerging Issues for Private Well Water and Drinking Water

Identifiable information about the respondent (name, position, agency, phone, and email) will be removed when the results of this assessment are aggregated for analysis. Individually identifiable state and local responses will be kept secure and will not be shared with CDC or anyone else without permission. This assessment is estimated to require an average of 40 minutes of your time. Thank you for completing this assessment by MONTH DAY, 2015. Please contact Jennifer Lemmings ([email protected] or 770­458­3811) if you have any questions. We appreciate your time and attention to this matter.

CDC estimates the average public reporting burden for this collection of information as 40 minutes per response, including the time for reviewing instructions, searching existing data/information sources, gathering and maintaining the data/information 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 burden to CDC/ATSDR Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-0879).

1. Please enter the following information about the primary respondent to this assessment.

Name:

Position:

Agency:

State/City:

Email Address:

Phone Number:

Unregulated Drinking Water

2. Has it been a priority for your state/city to seek funding to examine the public health issue of using private wells for drinking water?

• Yes

• No

• Don’t know

2. Select the non-infectious private well contaminants that are current public health priorities in your state/city. Check all that apply.

• Arsenic

• Metals (such as arsenic, lead, etc.)

• MTBE (Methyl tert-butyl ether) and other gasoline additives

• Nitrates

• Pharmaceuticals

• Personal care products

• Pesticides

• Other Radionuclides

• Radon

• Uranium

• Volatile Organic Compounds (VOCs)

• Other (specify)

2. Select the non-infectious private well contaminants that may impact public health in your state/city within the next ten years. Check all that apply.

• Arsenic

• Metals (such as arsenic, lead, etc.)

• MTBE (Methyl tert-butyl ether) and other gasoline additives

• Nitrates

• Pharmaceuticals

• Personal care products

• Pesticides

• Other Radionuclides

• Radon

• Uranium

• Volatile Organic Compounds (VOCs)

• Other (specify):

2. Are any of the following issues related to use of private wells for drinking water priorities in your state/city? Select all that apply.

• Demographics and locations of private well owners (“who and where are they?”)

• Drought

• Flooding

• Improving private well stewardship

• None are a priority at this time

• Other (specify):

2. What additional non-infectious issues related to use of private wells for drinking water do you expect might be priorities that may impact public health in your state/city in the next 10 years? Please list all that apply.

2. What type of technical assistance would your state/city find helpful to address current or future priority non-infectious private well drinking water issues? Select all that apply.

• Measuring exposure to toxic agents in private well water

• Investigating potential health effects from toxic agents in private well water

• Identifying and describing (e.g. demographics, stewardship practices, etc.) private well users

• Identifying populations of private well users that may be at higher risk of exposure to toxic agents in drinking water

• Measuring exposure to toxic agents before and/or after interventions to improve the quality of private well water

• Assessing associations between occurrence of disease and exposure to non-infectious contaminants in drinking water

• Identifying and prioritizing emerging groundwater contaminants with the highest potential to affect private well owners

• Other:

• None of the above (i.e., not interested in technical assistance at this time)

• Don’t know at this time

2. Does your state/city have a database of private well locations? Select only one option below.

• Yes

• No

• Don’t know

2. What does your database of well locations include? If yes to #8, what does it include?

• All wells

• Newly constructed wells only

• Other (specify):

2. Does your state/city have a database of private well water quality testing results? Select only one option below.

• Yes

• No

• Don’t know

2. Does your state/city have any of the following requirements for private wells? Select all that apply.

• Siting requirements

• Well construction standards

• Well construction permits or registration

• Don’t know

• Other (specify):

2. Does your state/city have water testing requirements for private wells? Select all that apply.

• No water testing requirements for private wells

• Immediately after construction

• At time of property transfer

• At regular intervals

• Other (specify):

13. You indicated that your state/city has water testing requirements for private wells, what contaminants are included in the required testing? Select all that apply.

• Bacteria

• Metals (e.g. arsenic, uranium, etc.) Specify:

• Nitrates

• Volatile organic compounds

• Pesticides

• Don’t know

• Other:

14. Does your state/city have current efforts to try to increase voluntary private well testing? Select only one option below.

• Yes

• No

• Don’t know

15. Do the efforts of your state/city to increase voluntary testing of private wells include any of the following components? Select all that apply.

• Providing free or reduced price testing

• Improving the convenience of providing a sample (e.g. collecting samples at local events such as fairs or locations such as schools, etc.)

• Disseminating information about the importance of testing (e.g. through a media campaign, website, local organizations, etc.)

• Other (specify):

16. Does your state/city have current efforts to try to educate private well owners regarding water treatment options? Select only one option below.

• Yes

• No

• Don’t know

16. Do your current education efforts include any of the following components? Select all that apply.

• Providing free or reduced price treatment systems

• Disseminating information about treatment options (e.g. website, etc.)

• Other (specify):

Regulated Drinking Water

16. Is exposure to and possible health effects from emerging unregulated contaminants in drinking water a priority public health issue in your state/city? Select only one option below.

• Yes

• No

• Don’t know

16. Which contaminants are of concern? List all that apply.

16. What type of technical assistance would your state/city find helpful to address the issues identified by possible health effects from unregulated contaminants? Select all that apply.

• Measuring exposure to toxic agents in drinking water

• Studying potential health effects from toxic agents in drinking water

• Other:

• None of the above (i.e., not interested in technical assistance at this time)

• Don’t know at this time

Private Drinking Wells—Regulated or Unregulated

16. How many documented illness clusters have been associated with private wells have been investigated in your state/city within the past five years? Please describe below.

16. Please provide any additional information that you think might be helpful or relevant to this assessment.

Thank you for taking the time to answer these questions. Your responses are invaluable to HSB’s decision making and planning of future activities. For more information, please visit resources at HSB’s website http://www.cdc.gov/nceh/hsb/cwh/default.htm.

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