Form 0920-0960 CDC Water and Health Study (web-based)

CDC Water and Health Study
Attachment I

CDC Water and Health Study

Form Approved
OMB No: 0920-0960
Exp 3/31/2016

Welcome to the CDC Water and Health Study!
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. Beginning the survey indicates
your consent to participate. For more information, please see the brochure enclosed in your survey
packet.
To begin the survey, click the Begin Survey button below.

Begin Survey

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Centers for Disease Control and Prevention

Department of Health

1600 Clifton Rd, Atlanta, GA 30333, U.S.A

and Human Services

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).

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CDC Water and Health Study

Instructions

While you are completing this survey, please use only the "Next" and "Previous" buttons found at the
bottom on each screen. DO NOT use your browser's back and next buttons. If you accidentally click
your browser's navigation button, you may be able to continue your survey by pressing the F5 key
(Windows), command + R keys (Mac) or by refreshing the web page.
You may stop and save your answers at any time by clicking on the "Stop" button found at the bottom of
each screen. If you choose to stop at any point, your answers to previous questions will be saved. You
can continue completing your survey at the point where you stopped by typing the link used to access the
survey into your web browser.

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Department of Health

1600 Clifton Rd, Atlanta, GA 30333, U.S.A

and Human Services

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CDC Water and Health Study

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

Feeding/watering animals
Filling wading or baby pool
Filling swimming pool or hot tub
Indoor or outdoor fountain
Vaporizer or humidifier
Nebulizer or CPAP
Nasal/sinus irrigation or Neti pot

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Department of Health

1600 Clifton Rd, Atlanta, GA 30333, U.S.A

and Human Services

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CDC Water and Health Study

Section 1: Household Water Use

2. At home, does anyone use hot water directly from the tap to make drinks or prepare instant foods?
Yes
No
Don't know

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Department of Health

1600 Clifton Rd, Atlanta, GA 30333, U.S.A

and Human Services

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CDC Water and Health Study

Section 1: Household Water Use

3. Does your home have a private well?
Yes
No
Don't know

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Department of Health

1600 Clifton Rd, Atlanta, GA 30333, U.S.A

and Human Services

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CDC Water and Health Study

Section 1: Household Water Use

4. Do you have a water softener in your home?
Yes
No
Don't know

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Department of Health

1600 Clifton Rd, Atlanta, GA 30333, U.S.A

and Human Services

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CDC Water and Health Study

Section 1: Household Water Use

5. What water filters are used in your home?
(check all that apply)
No water filter used
Water pitcher with filter
Refrigerator dispenser with filter
Filter on the faucet
Filter under the sink
Whole house filter
Other (please specify):
Don’t know
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Department of Health

1600 Clifton Rd, Atlanta, GA 30333, U.S.A

and Human Services

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CDC Water and Health Study

Section 2: Your Home

6. Which of the following best describes where you live?
House
Apartment or condominium
Townhouse or duplex
Mobile home
Other (please specify):

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Department of Health

1600 Clifton Rd, Atlanta, GA 30333, U.S.A

and Human Services

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CDC Water and Health Study

Section 2: Your Home

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

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Department of Health

1600 Clifton Rd, Atlanta, GA 30333, U.S.A

and Human Services

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CDC Water and Health Study

Section 2: Your Home

8. Are there any livestock located within 50 yards of your household?
(check all that apply)
No livestock
Cattle
Poultry
Pigs
Goats
Sheep
Horses
Other livestock (please specify):

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Department of Health

1600 Clifton Rd, Atlanta, GA 30333, U.S.A

and Human Services

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CDC Water and Health Study

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 the
survey 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.)
Yes
No
Don't know
• Did you completely lose water service? (For example, you turned on the faucet and nothing came out.)
Yes
No
Don't know
• Was any work done on the water pipes near your home?
Yes
No
Don't know
• Did anyone notice a change in the odor, taste, or color of tap water at home?
(check all that apply)
Change in odor
Change in taste
Change in color
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)
Yes
No
Don't know

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CDC Water and Health Study
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Centers for Disease Control and Prevention

Department of Health

1600 Clifton Rd, Atlanta, GA 30333, U.S.A

and Human Services

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CDC Water and Health Study

Section 3: Recent Water Service

You indicated that you were told to boil water before drinking it. What did you use for drinking water
during that time?
We only drank bottled water.
We always boiled our tap water before we drank it.
We sometimes boiled our tap water before we drank it.
We usually drank our tap water without boiling it first.

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1600 Clifton Rd, Atlanta, GA 30333, U.S.A

and Human Services

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CDC Water and Health Study

Section 4: People in Your Household

10. How many people, including you, live in your household?

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1600 Clifton Rd, Atlanta, GA 30333, U.S.A

and Human Services

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CDC Water and Health Study

Section 4: People in Your Household

The rest of the survey asks about the individual people in your household.
Please identify each person with initials. These do not have to be their real initials. 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

Person 2

Person 3

<--Select-->
<--Select-->

<--Select-->
<--Select-->

<--Select-->
<--Select-->

11. Person's Initials
12. Age (in years)
(If unsure of the exact age, please give
your best guess.)
13. Sex

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Department of Health

1600 Clifton Rd, Atlanta, GA 30333, U.S.A

and Human Services

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CDC Water and Health Study

Section 5: Drinking 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.
14. At home, which kinds of water does each person drink?
Person 1
(yourself - MJL)
Yes
No

Tap water, directly from the faucet (that you do not
filter)

Person 2
(JJ)
Yes
No

Person 3
(LM)
Yes
No

Water from a refrigerator dispenser

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

Bottled Water

Yes
No

Yes
No

Yes
No

Other

Yes
No

Yes
No

Yes
No

Please specify if Yes to "Other" above:

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Department of Health

1600 Clifton Rd, Atlanta, GA 30333, U.S.A

and Human Services

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CDC Water and Health Study

Section 5: Drinking Water Use

For questions 15 and 16, it does not matter if you filter the water.
(1 cup = 1/2 of a pint = 8 ounces)
Person 1
(yourself - MJL)

Person 2
(JJ)

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.

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Department of Health

1600 Clifton Rd, Atlanta, GA 30333, U.S.A

and Human Services

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Person 3
(LM)

CDC Water and Health Study

Section 6: Recent Activities

In this section, we are interested in recent activities you and your household members did during the 2week period. Please refer to the label on the front of the survey booklet or the enclosed calendar for the
dates of your 2-week period.
17. During the 2-week period, did anyone. . .

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

Person 1
(yourself - MJL)
Yes
No

Person 2
(JJ)
Yes
No

Person 3
(LM)
Yes
No

Swim in a pool?

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

Drink any water from a well?

Yes
No

Yes
No

Yes
No

Go hiking or camping?

Yes
No

Yes
No

Yes
No

Attend, work, or volunteer in
a day care?

Yes
No

Yes
No

Yes
No

Visit a petting zoo or farm
with animals?

Yes
No

Yes
No

Yes
No

Travel outside of the United
States?

Yes
No

Yes
No

Yes
No

Spend any nights away from
home?

Yes
No

Yes
No

Yes
No

Eat any meals prepared in a
restaurant? (includes deli,
fast food, take-out)

Yes
No

Yes
No

Yes
No

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Department of Health

CDC Water and Health Study

1600 Clifton Rd, Atlanta, GA 30333, U.S.A

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and Human Services

CDC Water and Health Study

Section 6: Recent Activities

17a. On the previous question, you indicated that the following household members spent nights away
from home during the two-week period. How many nights away from home did each of the following
household members spend during the 2-week period?
Person 1
(yourself - MJL)
Number of nights away from home:

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Department of Health

1600 Clifton Rd, Atlanta, GA 30333, U.S.A

and Human Services

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Person 2
(JJ)

CDC Water and Health Study

Section 6: Recent Activities

17b. In a previous question, you indicated that the following household members ate meals prepared in a
restaurant (includes deli, fast food, take-out) during the two-week period. About how many restaurant
meals did each of the following household members eat during the 2-week period?
Person 2
(JJ)

Person 3
(LM)

Number of restaurant meals:

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Department of Health

1600 Clifton Rd, Atlanta, GA 30333, U.S.A

and Human Services

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CDC Water and Health Study

Section 7: Stomach Problems

Please refer to the label on the front of the survey booklet or the enclosed calendar for the dates of the 2week period. In this section, we are asking about new stomach problems that started during the 2-week
period, not problems that you normally have.
18. During the 2-week period, did anyone start having new stomach problems (not problems they
normally have)?
Person 1
(yourself - MJL)
Yes
No

Vomiting?

Person 2
(JJ)
Yes
No

Person 3
(LM)
Yes
No

Nausea?

Yes
No

Yes
No

Yes
No

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

Yes
No

Yes
No

Yes
No

Abdominal pain or cramps?

Yes
No

Yes
No

Yes
No

Fever (100°F or higher) at the same time
as stomach problems?

Yes
No

Yes
No

Yes
No

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Department of Health

1600 Clifton Rd, Atlanta, GA 30333, U.S.A

and Human Services

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CDC Water and Health Study

Section 7: Stomach Problems

You indicated that the following household members had stomach problems during the 2-week period.
Person 1
(yourself - MJL)

Person 2
(JJ)

Person 3
(LM)

19. How many days did
the stomach problems
last?
20. When did the
stomach problems start?
  The date above is:

Exact
A best guess

Exact
A best guess

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1600 Clifton Rd, Atlanta, GA 30333, U.S.A

and Human Services

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Exact
A best guess

CDC Water and Health Study

Section 8: Stomach Problems - Illness Details

These questions are asking about how illnesses during the 2-week period affected you (or the people
listed below).
Person 1
(yourself MJL)

Person 2
(JJ)

Person 3
(LM)

22. Did anyone see a healthcare provider for stomach problems?

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

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

Yes
No

Yes
No

Yes
No

21. How many days of school or work did each person miss
because of stomach problems?
(enter number of days missed, enter 0 if no school or work
missed)

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

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1600 Clifton Rd, Atlanta, GA 30333, U.S.A

and Human Services

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CDC Water and Health Study

Section 9: Other Recent Illnesses or Symptoms

Please refer to the label on the front of the survey booklet or the enclosed calendar for the dates of the 2week period. In this section, we are asking about new symptoms that started during the 2-week period,
not symptoms that you normally have.
25. During the 2-week period, did anyone start having any of the following new symptoms?
Person 1
(yourself - MJL)
Yes
No

Cough?

Person 2
(JJ)
Yes
No

Person 3
(LM)
Yes
No

Sore throat?

Yes
No

Yes
No

Yes
No

Runny or stuffy nose?

Yes
No

Yes
No

Yes
No

Shortness of breath?

Yes
No

Yes
No

Yes
No

Rash?

Yes
No

Yes
No

Yes
No

Eye Infection (for example, pink eye)?

Yes
No

Yes
No

Yes
No

Ear Infection?

Yes
No

Yes
No

Yes
No

Fever (100°F or higher) at the same time as any of
these symptoms?

Yes
No

Yes
No

Yes
No

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and Human Services

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CDC Water and Health Study

Section 9: Other Recent Illnesses or Symptoms

On the previous question, you indicated that you experienced other recent symptoms during the 2-week
period.
Person 1
(yourself MJL)

Person 2
(JJ)

Person 3
(LM)

27. Did anyone see a healthcare provider for the new symptoms in
question 25?

Yes
No

Yes
No

Yes
No

28. Was anyone admitted to the hospital for at least one day as a
result of the new symptoms in question 25?

Yes
No

Yes
No

Yes
No

26. How many days of school or work did each person miss
because of new symptoms in question 25?
(enter number of days missed, enter 0 if no school or work
missed)

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Department of Health

1600 Clifton Rd, Atlanta, GA 30333, U.S.A

and Human Services

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CDC Water and Health Study

Section 10: More About People in Your Household

Person 1
(yourself MJL)

Person 2
(JJ)

Person 3
(LM)

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

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

Yes
No

Yes
No

Yes
No

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Department of Health

1600 Clifton Rd, Atlanta, GA 30333, U.S.A

and Human Services

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CDC Water and Health Study

Section 11: Demographic Information
Person 1
(yourself MJL)
Yes
No

31. Is each person of Hispanic or Latino ethnicity?
32. What is each person’s race?
(Mark one or more boxes below.)
     American Indian or Alaska Native
     Asian
     Black or African American
     Native Hawaiian or other Pacific Islander
     White

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1600 Clifton Rd, Atlanta, GA 30333, U.S.A

and Human Services

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Person 2
(JJ)

Person 3
(LM)

Yes
No

Yes
No

CDC Water and Health Study

Section 12: Additional Comments

33. Are there any additional comments or information that you would like to provide?

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