Drinking Water Needs Assessment Form
Please complete this form to help us understand your drinking water usage, sources, concerns, and support needs. All responses are important for a comprehensive assessment.
Location or Household Name
*
How many people does this water supply serve?
*
What is your primary drinking water source?
*
Municipal tap water
Private well
Community well
Bottled water
Rainwater
Other
On average, how much drinking water do you use daily (in liters or gallons)?
*
Do you currently use any water filtration or treatment?
*
No filtration or treatment
Basic filter (pitcher, faucet, etc.)
Reverse osmosis system
Boiling
Other
What concerns do you have about your drinking water quality? (Select all that apply)
*
Taste or odor
Color or cloudiness
Sediment or particles
Possible contaminants (lead, bacteria, etc.)
Water pressure or flow
No concerns
Other
What type of support or solution are you most interested in?
*
Improved filtration system
Bottled water delivery
Water quality testing
Education on safe water practices
Other
How urgent is your need for drinking water support?
*
1
2
3
4
5
How easy is it for your household to access drinking water?
*
Very difficult
1
2
3
4
Very easy
5
1 is Very difficult, 5 is Very easy
Additional notes or comments
Submit Assessment
Should be Empty: