Dimock Water Exposure Investigation

Form approved

0923-0048

Exp Date:

03/31/2019

Attachment 4:

Questionnaire for the Dimock Water Exposure Investigation

OMB #0923-0048

Name of Surveyor: Date:

I just want to repeat my name is #######. Now since we have your permission, we would now like to ask you some questions.

Water History:

1. What is the main source of drinking water in your home?

Private Well

City or County (public)

Spring

Pond

Cistern

Supplied Bulk

Bottled

Other: (specify)

Don’t know

Refused

ATSDR estimates the average public reporting burden for this collection of information as 20 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 this burden to CDC/ATSDR Information Collection Review Office, 1600 Clifton Road

NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0923-0048).

2. Has the water from your private well ever been tested at any time other than by EPA in 2012?

Yes

No

Don’t know

Refused

If “yes” do you know the date it was tested who did the testing, whether it was tested for bacterial and/or chemical contamination, and the results?

______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

3. What is your main source of water for cooking?

Private Well

City or County (public)

Spring

Pond

Cistern

Supplied Bulk

Bottled

Other: (specify)

Don’t know

Refused

4. What is the main source of water for bathing and showering?

Private Well

City or County (public)

Spring

Pond

Cistern

Supplied Bulk

Bottled

Other: (specify)

Don’t know

Refused

5. What is the main source of water for pools and/or hot tubs (to include “kiddie” or wading pools)?

Private Well

City or County (public)

Spring

Pond

Cistern

Supplied Bulk

Bottled

Other: (specify)

Don’t know

Refused

6. List all of the water treatment devices for your drinking water or water used for mixing drinks (e.g. baby formula, juices)

None

Charcoal Filter/Granular Activated

Ceramic Filter

Reverse Osmosis

Water Softener

Distillation

Sediment Filter

Aerator

Water Filter system (e.g. Brita, Pur, etc.)

Iron Removal System

Chlorinator

Don’t know

Refused

7. List all of the water treatment devices for your water used for cooking.

None

Boil water

Charcoal Filter/Granular Activated

Ceramic Filter

Reverse Osmosis

Water Softener

Distillation

Sediment Filter

Aerator

Water Filter system (e.g. Brita, Pur, etc.)

Iron Removal System

Chlorinator

Don’t know

Refused

8. List all of the water treatment devices for your bathing and showering water.

None

Charcoal Filter/Granular Activated

Ceramic Filter

Reverse Osmosis

Water Softener

Boil water

Distillation

Sediment Filter

Aerator

Water Filter system (e.g. Brita, Pur, etc.)

Iron Removal System

Chlorinator

Don’t know

Refused

9. If you use filters, do you maintain them according to the manufacturers recommendations or if you have a whole house filter do you have a contractor maintain them?

Yes

No

Don’t know

Refused

10. If you use a Water Softener, do you regularly maintain it?

Yes

No

Don’t know

Refused

11. If yes, what is the brand and age of the Water Softener?

Brand: __________________________________________________________

Age: __________________________________________________________

Don’t know

Refused

12. Do you know the depth of your water well or have any records of the well history of your private water well?

Yes

No

Don’t know

Refused

1. If yes, please provide details (type, age, depth of well)

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

13. Do you obtain bulk water for drinking or household use?

Yes

No

Don’t know

1. If you answered “yes”, how long have you used bulk water?­­­­­­­­­­­­­­­­­­­­­­­­­­____________________________

2. What is the source of your bulk water?______________________________________________

3. What do you use bulk water for (e.g., drinking, cooking, showering, laundry, etc.)_______________________________________________________________________________

4. Do you have any comments regarding the quality and taste of the bulk water? ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

14. Do you know of any natural gas extraction activities currently occurring near your home?

Yes

No

Don’t know

15. If yes, please explain __________________________________________________________________________________________________________________________________________________________________________________________

16. Have you ever had your home tested for radon gas? If so, what was the result? ___________________________

Yes

No

Don’t know

General Information:

1. First name (please spell): _______________________________

2. Last name (please spell): _______________________________

3. Middle initial: __________________

4. How long have you lived at this address?

< 1 year

1-10 years

>10 years

Don’t know

Refused

Demographic Information:

1. Gender ______

2. Age at time of survey _____

Refused

3. Race :

American Indian or Alaska Native

Asian

Black or African American

Native Hawaiian or Other Pacific Islander

White

Refused

4. Ethnicity:

Hispanic or Latino

Not Hispanic or Latino

4. How many people live here fulltime? ________ (if more than 1 person complete General Information question 4 and Demographic Information for each resident)

NOTE: Surveyor/Sampling team will also consult with home owner to diagram the location of a water supply well, septic system, home heating oil tank, and natural gas well pads at the residence of in the immediate vicinity of the property.