Water Supply Impact Survey
Help us assess the impact of water supply issues in your area. Please answer the following questions to the best of your knowledge.
What is the current status of your water supply?
*
Fully operational
Intermittent supply
Low pressure
No supply
How long have you experienced this water supply issue?
*
Less than 1 hour
1–6 hours
6–24 hours
More than 24 hours
What is your primary water source?
*
Municipal supply
Well/Borehole
Rainwater
Other
How would you rate the overall impact of this water supply issue on your daily activities?
*
1
2
3
4
5
Which areas of your life are most affected by the water supply issue? (Select all that apply)
Drinking water
Cooking
Cleaning/Sanitation
Personal hygiene
Gardening/Outdoor use
Other
Have you noticed any non-medical health or safety concerns related to the water supply issue?
No concerns observed
Minor inconvenience (e.g., handwashing, cleaning)
Potential safety issue (e.g., slippery floors, lack of sanitation)
How urgent do you feel it is to resolve this water supply issue?
*
Not urgent
1
2
3
4
Extremely urgent
5
1 is Not urgent, 5 is Extremely urgent
Please share any additional comments or observations.
Submit Survey
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