Clean Water Health Impact Survey
Help us understand how the quality of your water source influences your health and daily life. Your responses are anonymous and will be used to improve water safety and community well-being.
What is your primary source of household water?
*
Municipal tap water
Well water
Bottled water
Rainwater
Other
How would you rate the quality of your main water source?
*
1
2
3
4
5
Have you noticed any of the following issues with your water? (Select all that apply)
Unpleasant taste
Odor
Cloudiness
Sediment or particles
None of the above
In the past 6 months, how often have you or your household experienced any of the following? Please select the frequency for each.
*
Rows
Never
Rarely
Sometimes
Often
Upset stomach or digestive issues
1
2
3
4
Skin irritation
5
6
7
8
Unusual fatigue
9
10
11
12
No related symptoms
13
14
15
16
To what extent do you agree with the following statements?
*
Rows
Strongly disagree
Disagree
Neutral
Agree
Strongly agree
I am concerned about the safety of my water source.
17
18
19
20
21
Water quality affects my daily routines.
22
23
24
25
26
I take extra steps to treat or filter my water.
27
28
29
30
31
I would like more information about water quality in my area.
32
33
34
35
36
How has water quality impacted your daily life or routines? (Optional)
What is your age group?
*
Please Select
Under 18
18-24
25-34
35-44
45-54
55-64
65 or older
Prefer not to say
Which best describes your area?
*
Urban
Suburban
Rural
If you would like to be contacted for follow-up or to receive survey results, please provide your email address (optional):
example@example.com
Submit Survey
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