Pollution Feedback Survey Form
Share your observations about pollution in your area to help us understand and address local environmental concerns.
Location or Area Affected
*
Type of Pollution Observed
*
Air
Water
Noise
Soil
Other
When did you notice the pollution?
*
-
Month
-
Day
Year
Date
How severe does the pollution seem?
*
Not severe
1
2
3
4
Very severe
5
1 is Not severe, 5 is Very severe
How often does this pollution occur?
*
Once
Occasionally
Frequently
Constantly
What impact has the pollution had on the area?
Rows
No impact
Minor impact
Moderate impact
Severe impact
Health of residents
1
2
3
4
Wildlife
5
6
7
8
Property/Infrastructure
9
10
11
12
Local businesses
13
14
15
16
Have you observed any possible source or cause?
*
Yes
No
If yes, please describe the source or cause observed
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Additional comments or suggestions
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