Water Supply Fatigue Survey Form
Help us understand how water supply conditions may affect feelings of fatigue in your daily life. Your responses are anonymous and will be used for research and improvement purposes only.
How reliable is your current water supply?
*
Very reliable
Mostly reliable
Somewhat unreliable
Very unreliable
How often do you experience interruptions in your water supply?
*
Never
Rarely
Sometimes
Often
Very often
How would you rate your average level of fatigue during days with normal water supply?
*
1
2
3
4
5
How would you rate your average level of fatigue during days with water supply interruptions?
*
1
2
3
4
5
To what extent do you agree with the following statements?
*
Rows
Strongly disagree
Disagree
Neutral
Agree
Strongly agree
Water interruptions disrupt my daily routine
1
2
3
4
5
Water supply issues increase my stress
6
7
8
9
10
I feel more tired when water is unavailable
11
12
13
14
15
How do you typically cope with water supply interruptions?
*
Store water in advance
Reduce physical activities
Delay household chores
Seek alternative water sources
Other
On average, how many hours per week is your water supply unavailable?
*
How much does water supply impact your ability to rest or recover?
*
No impact
1
2
3
4
5
6
7
8
9
Major impact
10
1 is No impact, 10 is Major impact
What is your primary source of water?
*
Municipal supply
Well or borehole
Delivered water
Other
If you would like to share any additional comments about water supply and fatigue, please do so here:
Submit Survey
Should be Empty: