Environmental Pollution Survey Form
Share observations about environmental pollution in your area, including the type, severity, source, impacts, and any additional details.
Survey Context
Location or Area Affected
*
Primary Pollution Type Observed
*
Air
Water
Soil
Noise
Light
Mixed
Other
When Was the Issue First Noticed?
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
How Often Is It Observed?
*
Daily
Weekly
Monthly
Occasionally
Rarely
First Time
Other
Pollution Details
Main source or suspected cause of pollution
*
Industrial discharge
Agricultural runoff
Vehicle emissions
Construction dust
Improper waste disposal
Sewage leakage
Oil/chemical spill
Natural cause
Unknown
Other
Severity level of pollution observed
*
Very low
1
2
3
4
Very high
5
1 is Very low, 5 is Very high
Visible effects or symptoms noticed
Discolored water
Strong odor
Smoke or haze
Dead or stressed vegetation
Fish or wildlife affected
Unusual residue or foam
Dust accumulation
Noise disturbance
Eye or throat irritation
Other
Impact and Follow-up
Who or what is most affected?
*
People
Wildlife
Plants
Water bodies
Soil
Air quality
Property
Other
Additional comments or evidence description
Would you like follow-up about this report?
*
Yes
No
Submit
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