Environmental Degradation Survey
Report and assess local environmental degradation using the same title consistently throughout the form.
Respondent and Location
Respondent Name
First Name
Last Name
Email Address
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Affected Location / Site
*
Environmental Impact Survey
Primary type of degradation observed
*
Air pollution
Water pollution
Soil erosion
Deforestation
Habitat loss
Waste accumulation
Noise pollution
Other
Severity of impact
*
Low
1
2
3
4
High
5
1 is Low, 5 is High
When was it first noticed?
*
Please Select
Today
Within the past week
Within the past month
Within the past year
More than a year ago
Not sure
Affected area extent
*
Localized small area
Moderate area
Widespread area
Very widespread
Not sure
Likely source or cause
Industrial activity
Vehicle emissions
Agricultural practices
Construction activity
Illegal dumping
Deforestation/logging
Natural causes
Other
Visible indicators
Rate the observed impacts
*
Rows
None
Low
Moderate
High
Severe
Air quality
1
2
3
4
5
Water quality
6
7
8
9
10
Vegetation loss
11
12
13
14
15
Wildlife disturbance
16
17
18
19
20
Waste presence
21
22
23
24
25
Additional Notes
Additional comments, details, or observations
Upload supporting environmental evidence (photos, documents, or relevant files)
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