Water Usage Impact Survey Form
Please complete the Water Usage Impact Survey Form to help us understand water-use patterns and concerns. Your responses will support effective water management planning.
Location or Site Type
*
Please Select
Urban household
Rural household
Commercial facility
Industrial facility
Agricultural site
Other
Household or Facility Type
*
Please Select
Single-family home
Multi-family building
Office building
Factory/Plant
Farm
Other
Primary Water Source
*
Municipal supply
Private well
Surface water (river/lake)
Rainwater harvesting
Other
Estimated Average Monthly Water Usage (in cubic meters or gallons)
*
Main Water-Using Activities (select all that apply)
*
Drinking/cooking
Bathing/sanitation
Laundry
Irrigation/gardening
Industrial processes
Livestock
Other
Have there been any recent changes in your water usage?
*
Yes, increased
Yes, decreased
No significant change
How would you rate the impact of current water availability on your household or site?
*
No impact
1
2
3
4
Severe impact
5
1 is No impact, 5 is Severe impact
Which water conservation measures are already in use? (Select all that apply)
*
Low-flow fixtures
Rainwater collection
Greywater reuse
Leak detection/repair
Water-efficient appliances
Behavioral changes
Other
What are your top concerns related to water use? (Select up to 2)
*
Water cost
Supply reliability
Water quality
Environmental impact
Regulations/compliance
Other
Additional comments or observations
Submit Survey
Should be Empty: