Paper-based Questionaire

Attachment J

Form Approved

0920-0960
Exp 03/31/2016

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 (0920-0960).

Section 1 Household Water Use
In this first section, we’d like to ask some general questions about your household water use.
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.

1

Please mark all of the ways that you and the
people in your household have used tap
water in the last 30 days. (check all that apply)

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

2

At home, does anyone use hot water directly
from the tap to make drinks or prepare
instant foods?

o Yes
o No
o Don’t know

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 
Whole house filter
o 

Other (please specify________________________)
o Don’t know

(check all that apply)

o Feeding/watering
animals
o Filling wading or
baby pool
o Filling swimming 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
you live? (check only one)

7

What pets do you have in your home or yard? o 
No pets
(check all that apply)
o 
Adult dog
o 
Puppy
o 
Adult cat
o 
Kitten
o 
Hamster, gerbil, or mouse
o 
Bird
o 
Reptile or amphibian (for example, turtle, snake,
iguana, frog, chameleon, salamander)
o 
Fish
o 
Other (please specify______________________)

8

Are there any livestock located within 50
yards of your household?
(check all that apply)

o 
House
o 
Apartment or condominium
o 
Townhouse or duplex
o 
Mobile home
o 
Other (please specify______________________)

o 
No livestock
o 
Cattle
o 
Poultry
o 
Pigs
o 
Goats
o 
Sheep
o 
Horses
o 
Other livestock (please specify________________)

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 2-week period.

9

At any time during the 2-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

 Was any work done on the water pipes
near your home?

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?
Please enter number in box.

People

The rest of the survey asks about the individual people in your household.
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 2 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’s initials

12

Age (in years)

13

Sex

Person 2

Person 3

Person 4

Person 5

Person 6

Male
Female

Male
Female

Male
Female

Male
Female

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

Male
Female

Male
Female

Go on to next page

Section
5 D
Section
4 rinking Water Use
On this page, we are asking about drinking water from your water utility, or “tap water,” that comes
from your house, as well as other kinds of water you drink.
Person 1
(yourself)

Person 2

Person 3

Person 4

Person 5

Person 6

Person’s initials
(copy from Question 11)
14

At home, which kinds of water does each person usually drink? Circle yes or no for each kind of water.
 Tap water, directly from
the faucet (that you do not
filter)?

Yes
No

Yes
No

Yes
No

Yes
No

Yes
No

Yes
No

 Water from a refrigerator
dispenser?

Yes
No

Yes
No

Yes
No

Yes
No

Yes
No

Yes
No

 Tap water that you filter (for
example, filter in pitcher,
on faucet, under sink)?

Yes
No

Yes
No

Yes
No

Yes
No

Yes
No

Yes
No

 Bottled water?

Yes
No

Yes
No

Yes
No

Yes
No

Yes
No

Yes
No

 Other (please specify)
______________________

Yes
No

Yes
No

Yes
No

Yes
No

Yes
No

Yes
No

________________________________________________________________________________
For questions 15 and 16, it does not matter if you filter the water. (1 cup = ½ of a pint = 8 ounces)
15

On average, about how many
cups of your home tap water
does each person drink per
day?

16

On average, about how many
cups of cold drinks mixed
with your home tap water,
such as Kool-Aid, infant
formula, instant iced tea, or
watered-down juice, does
each person drink per day?
Do not include hot beverages,
like brewed coffee or tea.

Cups

Cups

Cups

Cups

Cups

Cups

Cups

Cups

Cups

Cups

Cups

Cups

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 2-week period. Please refer to the label on the front of this booklet or the enclosed calendar for
the dates of your 2-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 2-week period,
did anyone

Circle Yes or No for each person.

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

Yes
No

Yes
No

Yes
No

Yes
No

Yes
No

Yes
No

 Swim in a pool?

Yes
No

Yes
No

Yes
No

Yes
No

Yes
No

Yes
No

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

Yes
No

Yes
No

Yes
No

Yes
No

Yes
No

Yes
No

 Drink any water from a
well?

Yes
No

Yes
No

Yes
No

Yes
No

Yes
No

Yes
No

 Go hiking or camping?

Yes
No

Yes
No

Yes
No

Yes
No

Yes
No

Yes
No

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

Yes
No

Yes
No

Yes
No

Yes
No

Yes
No

Yes
No

 Visit a petting zoo or farm
with animals?

Yes
No

Yes
No

Yes
No

Yes
No

Yes
No

Yes
No

 Travel outside of the
United States?

Yes
No

Yes
No

Yes
No

Yes
No

Yes
No

Yes
No

 Spend any nights away
from home?

Yes
No

Yes
No

Yes
No

Yes
No

Yes
No

Yes
No

Yes
No

Yes
No

Yes
No

Yes
No

Yes
No

Yes
No

 How many nights away
from home?
 Eat any meals prepared in
a restaurant? (includes deli,
fast food, take-out)

 About how many
restaurant meals?
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
2-week period. In this section, we are asking about new stomach problems that started during the
2-week period, 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 2-week period, did anyone start having new stomach problems (not problems they
normally have)? Circle Yes or No for each person.
 Vomiting?

Yes
No

Yes
No

Yes
No

Yes
No

Yes
No

Yes
No

 Nausea?

Yes
No

Yes
No

Yes
No

Yes
No

Yes
No

Yes
No

 Diarrhea? (3 or more loose
stools in a 24-hour period)

Yes
No

Yes
No

Yes
No

Yes
No

Yes
No

Yes
No

 Abdominal pain or
cramps?

Yes
No

Yes
No

Yes
No

Yes
No

Yes
No

Yes
No

 Fever (100oF or higher)
at the same time as
stomach problems?

Yes
No

Yes
No

Yes
No

Yes
No

Yes
No

Yes
No

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

How many days did the
stomach problems last?

20

When did the stomach
problems start? (MM/DD/YY)
This date is:

__/__/__
[ ] Exact

__/__/__
[ ] Exact

__/__/__
[ ] Exact

__/__/__
[ ] Exact

__/__/__
[ ] Exact

__/__/__
[ ] Exact

[ ] Best guess [ ] Best guess [ ] Best guess [ ] Best guess [ ] Best guess [ ] Best guess

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

Go on to next page

Section 8 Illness Details - Stomach Problems
Please complete the section only if you answered Yes to any symptoms in
section 7. If no one had stomach problems in the 2-week period, you can skip to
section 9 on the next page.
These questions are asking about how stomach problems during the 2-week period affected you.
Person 1
(yourself)

Person 2

Person 3

Person 4

Person 5

Person 6

Person’s initials
(copy from Question 11)
Enter number of days missed, enter 0 if no school or work missed
21

How many days of school or
work did each person miss
because of stomach problems?
Circle Yes or No for each person.

22

Did anyone see a healthcare
provider for stomach
problems?

Yes
No

Yes
No

Yes
No

Yes
No

Yes
No

Yes
No

23

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

Yes
No

Yes
No

Yes
No

Yes
No

Yes
No

Yes
No

24

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

Yes
No

Yes
No

Yes
No

Yes
No

Yes
No

Yes
No

Do you have any other information
to share about recent stomach
problems?

_________________________________________________________
_________________________________________________________
_________________________________________________________

Go on to next page

Section 9 Other Recent Illnesses or Symptoms
Please refer to the label on the front of this booklet or the enclosed calendar for the dates of the
2-week period. In this section, we are asking about new illness or symptoms that started during the
2-week period, 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)
25

During the 2-week period, did anyone start having any of the following new symptoms?
Circle Yes or No for each person.

 Cough?

Yes
No

Yes
No

Yes
No

Yes
No

Yes
No

Yes
No

 Sore throat?

Yes
No

Yes
No

Yes
No

Yes
No

Yes
No

Yes
No

 Running or stuffy nose?

Yes
No

Yes
No

Yes
No

Yes
No

Yes
No

Yes
No

 Shortness of breath?

Yes
No

Yes
No

Yes
No

Yes
No

Yes
No

Yes
No

 Rash?

Yes
No

Yes
No

Yes
No

Yes
No

Yes
No

Yes
No

 Eye infection (for example,
pink eye)?

Yes
No

Yes
No

Yes
No

Yes
No

Yes
No

Yes
No

 Ear infection?

Yes
No

Yes
No

Yes
No

Yes
No

Yes
No

Yes
No

 Fever (100oF or higher) at
the same time as these
symptoms?

Yes
No

Yes
No

Yes
No

Yes
No

Yes
No

Yes
No

If anyone had ANY symptoms in question 25, please answer questions 26, 27 and 28.
Enter number of days missed, enter 0 if no school or work missed
26

How many days of school or
work did each person miss
because of these symptoms?

27

Did anyone see a healthcare
provider for these symptoms?

Yes
No

Yes
No

Yes
No

Yes
No

Yes
No

Yes
No

28

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

Yes
No

Yes
No

Yes
No

Yes
No

Yes
No

Yes
No

Go on to next page

Section 10 More About People in Your Household
Person 1
(yourself)

Person 2

Person 3

Person 4

Person 5

Person 6

Person’s initials
(copy from Question 11)
Circle Yes or No for each person.
29

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)?

Yes
No

Yes
No

Yes
No

Yes
No

Yes
No

Yes
No

30

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

Yes
No

Yes
No

Yes
No

Yes
No

Yes
No

Yes
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.

31

Is each person of Hispanic or
Latino ethnicity?

Person 1
(yourself)

Person 2

Person 3

Person 4

Person 5

Person 6

Yes
No

Yes
No

Yes
No

Yes
No

Yes
No

Yes
No

What is each person’s race? (Mark one or more boxes.)
32

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

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

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

Fold along dotted line and place in envelope.

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