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Community Water Quality Survey

Are you a homeowner?
Yes
No - Renter
What source of water do you have in your home?
City
County
Community Well
Private Well
Please check any conditions that you currently experience:
Chlorine Smell
Rust Stains
Salty Taste
Blue-Green Stains
Rotten Egg Smell
Other
Please Specify:
Last year you had your water tested? (Type "Never" if not applicable)
Do you currently use any water filtration system?
None
Fridge
Britta
Water Softener
Reverse Osmosis
Other
Please Specify:
How often do you have to change filters in your home that involve water? (Brita, Fridge, Keurig, etc)
Monthly
Bi-Monthly
Quarterly
Half a year
Yearly
Do you buy bottled water?
Yes
No
To estimate water usage, how many people live in your home?
1
2
3
4
5
6
7
8
9
10
Does anyone in the family have skin irritations such as Eczema, Psoriases, etc?
Yes
No
Please rate your water:
Good
Fair
Poor
Is there anything you would change about your water?
For classification purposes, please select your gender:
Male
Female
Prefer not to answer
For classification purposes, please select your age group:
18-24 years old
25-34 years old
35-44 years old
45-54 years old
55-64 years old
65+ years old
For classification purposes, please select your annual household income:
Less than $20,000
$20,001 to $34,999
$35,000 to $49,999
$50,000 to $64,999
$65,000 to $79,999
$80,000 to $99,999
$100,000 +
Which of the following best describes you?
Black or African American
White or Caucasian
Hispanic/Latino
Asian
Native American/Pacific Islander
Mixed
Other
Prefer not to answer
What is the highest level of education that you have completed?
Some high school or less
High school graduate
Trade school graduate
Some College
College Graduate
Some Post Graduate school
Post Graduate
Prefer not to answer
Are you:
Married
Single, Never been married
Single, living with partner
Divorced
Widowed
Prefer not to answer
How likely are you to purchase a water treatment system for your home if it did not affect your monthly budget?
Very Likely
Likely
Neither likely nor unlikely
Unlikely
Very Unlikely
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