Example Questionnaire

Attachment H

Example Questionnaire

Form Approved

OMB No. 0920-XXXX

Exp. Date xx/xx/20xx

Sample questionnaire introduction for investigation that includes collecting questionnaire data and environmental samples:

Thank you for taking our investigation. The questions in our questionnaire should take less than thirty five minutes. After that, we will be offering free {FILL IN TYPE(S)} = [FOR ENVIRONMENTAL-air, soil, water, foods testing] Once we are done with this investigation, you will be given a copy of the testing results. Generally, we are able to get results to you within {FILL IN ADJUSTED TIME FRAME OR INSERT 4 – 8 WEEKS}.

Sample questionnaire introduction for investigation that includes collecting questionnaire data and biologic specimens:

Thank you for taking part in our investigation. The questions in our questionnaire should take less than thirty five minutes. After that, we will be offering free {FILL IN TYPE(S)} = [FOR BIOLOGIC-blood, urine, hair, nails, other testing for you]. Once we are done with this investigation, you will be given a copy and details of your test results. Generally, we are able to get results to you within {FILL IN ADJUSTED TIME FRAME OR INSERT 4 – 8 WEEKS}.

CDC estimates the average public reporting burden for this collection of information as 35 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, Ga. 30333; ATTN: PRA (0920-xxxx).

Interviewer Name: ________________________ Interview Location: _______________________________

Participant ID: _______________________ Date of Interview: _________/________/______ (month/day/year)

Phone (____) _________________________

Participant Name: ________________________________________________

Mailing Address: ________________________________________________

City: _____________________ Zip code: ________________

Physical Address: ________________________________________________

City: _____________________ Zip code: ________________

GPS (at well head): _____________________

Sociodemographics

1. How old are you (in years)? ________

2. What is your sex?

• Male

• Female

• Refused

3. Please tell us how many people in your household (including yourself) are in the following age categories:

Age Category	How many in the household
Less than 2 years old
2 years-17 years old
18 years-64 years old
More than 64 years old

4. What is the highest grade of school that you completed?

• Did not graduate high school

• High School Graduate

• Some College

• Associates Degree

• Bachelors Degree

• Post Graduate Degree

• Refused

5. Before taxes, what is your total yearly household income?

• Less than $10,000

• $10,000-24,999

• $25,000-49,999

• $50,000-74,999

• $75,000-99,999

• $100,00-150,000

• Greater than $150,000

• Refused

6. What is your ethnicity?

• Hispanic or Latino

• Not Hispanic or Latino

7. What is your race?

• American Indian or Alaska Native

• Asian

• Black or African American

• Native Hawaiian or Other Pacific Islander

• White

• Refused

Household water source

8. How long have you lived in your home?

________________ (months/years)

 Refused

9. How would you describe the physical condition of your well (including your well pump and well casing, or the tube that is placed in the drilled hole to maintain the well opening)?

• Good condition

• Minor problems

• Deteriorating

• Don’t know

• Refused

10. How deep is your well? ______________ ft  Don’t know  Refused

11. How old is your well? ______________ ft  Don’t know  Refused

12. During the past year, have you ever had a problem with your well providing insufficient water for household uses?

• Yes

• No

• Don’t know

• Refused

13. During the past year, have you ever had any concerns with the quality of your well water?

• Yes Describe: ____________________________________________________

• No

• Don’t know

• Refused

Household water use

14. How many 8 oz. glasses of water (including water for making other beverages, such as coffee or orange juice) have you drunk from your well in the last 24 hours?: ______ glasses

15. In the past week, where do you usually get your drinking and cooking water? [Rank order, 1=most and 4=least]

• Your Well: ___________

• Bottled Water: ___________

• Water from a Filter Jug: ___________

• Other sources: ___________ Specify: ___________________________

16. When at home, what is the main reason that you drink water from sources other than your well?

• Bad taste

• Bad smell

• Bad appearance

• Convenience

• I don’t, I only use tap water

• Other, please specify: _______________________________

• No reason

17. When you cook with water, how often do you use the tap water from your private well? (e.g., soups, pasta, rice, etc.)?

• Always

• Most of the time

• Half of the time

• Infrequently

• Never

18. Do you use any of the following water filters in your home? Check all that apply.

• Jug or pitcher filter

• Faucet-mounted filter

• Counter-top filter

• Under-sink filter

• Reverse-osmosis system

• Refrigerator filter

• Whole house system (a single system that treats all the water in your house)

• Other (specify):

• You do not use a water filter in your home

17a. If you use a filter in your home, do you regularly replace and maintain the filters?

• Yes

• No

• Don’t know

• Refused

Exposure information

19. What kind of work do you do (for example, registered nurse, computer specialist, cashier, auto

mechanic, etc.)? ______________________________________________________________________________

20. What kind of business or industry do you work in (for example, hospital, elementary school,

laboratory, clothing manufacturing, restaurant, etc.)? ______________________________________________________________________________

21. Have you eaten or drunk any of the following in the past 3 days?

a. Fish (including fresh fish, fish sticks, canned tuna fish, fish sandwiches, etc.)	 Yes	 No
b. Shellfish (shrimp, oyster, crab, etc)	 Yes	 No
c. Rice	 Yes	 No
d. Homeopathic, home, folk, or natural remedies	 Yes	 No

22. Have you used any pesticides including animal repellant, fungicide, herbicide, insecticide, etc. to get rid of insects, rodents, weeds, or other pests in the past 3 days?

• Yes

• No

22a. If yes, was that done inside your home, outside your home, or both?

• Inside

• Outside

• Both

23. What hobbies, excluding sports, (for example, ceramics, jewelry making, painting), do you have? _____________________________________________________________________________

24. Do you smoke?

• Yes

• No

25. Has anyone smoked tobacco (such as cigarettes) in the home in the last 3 days?

• Yes

• No

Health status

26. How would you describe your overall health?

• Excellent

• Very good

• Good

• Acceptable

• Poor

• Don’t know

27. Do you have any of the following medical problems?

• Diabetes type I or II

• Kidney disease

• High Blood Pressure

• Anemia, from low iron

• Bone problems or disease (like osteoporosis or “brittle bones”)

• Chronic Respiratory Illness such as Asthma and Chronic Obstructive Pulmonary Disease (COPD)

• Sickle Cell Anemia or Trait

• G-6-P-D deficiency

28. Do you have any health concerns about drinking your well water?

• Yes

• No

29. If yes, what are your health concerns? Check all that apply.

• Gastrointestinal illness

• Headaches

• Cancer

• Other:____________________________________________________________

30. Have you ever been diagnosed by a healthcare provider with an illness they attributed to drinking well water?

• Yes If yes, specify type: _______________________________

• No

• Don’t know

• Refused

31. During the past year, have you ever been worried about the quantity of water your well provided for household uses?

• Yes If yes, describe: _______________________________

• No

• Don’t know

• Refused

32. During the past year, have you ever been worried about the quality of your well water?

• Yes If yes, describe: _______________________________

• No

• Don’t know

• Refused

Perceptions and practices that could impact an individual’s exposure level

33. In your opinion, how would you rate the following characteristics of your well water?

Taste: Very good Good Neutral Bad Really bad

Smell: Very good Good Neutral Bad Really bad

Appearance: Very good Good Neutral Bad Really bad

Safety: Very good Good Neutral Bad Really bad

34. When was the last time your well water was tested?

• Within the last year

• More than one year ago but less than five years ago

• More than five years ago

• My well has never been tested Go to Question 36.

• Don’t know Go to Question 36.

35. The last time your well water was tested, what did you test for? Check all that apply.

• Arsenic

• Bacteria/germs

• Chloride

• Color

• Copper

• Fluoride

• Hardness

• Iron

• Lead

• Manganese

• Nitrates

• Pesticides

• pH

• Radionuclides (Uranium, Radon, Radium)

• Sulfate

• Total dissolved solids

• Volatile Organic Compounds (VOCs)

• Other (specify):

• Don’t know

36. Have you ever received the results of the testing?

• Yes

• No Skip to 38.

35a. If yes, what did the results tell you about your well water quality?:____________________

35b. If yes, what actions did you take as a result of receiving your well results?:________________

37. I should test my well to make sure that my water is safe.

• Strongly Agree

• Agree

• Disagree

• Strongly Disagree

38. I would be more likely to test my well if I received a public notice from the county/state about water contamination in my neighborhood.

• Strongly Agree

• Agree

• Disagree

• Strongly Disagree

39. I would be more likely to test my well if I knew what contaminants to test for.

• Strongly Agree

• Agree

• Disagree

• Strongly Disagree

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