Community Survey

Community Survey

Harris County Pollution Control is conducting research on your concern for pollution in your community. The survey should take approximately 20 minutes. You can only take the survey once. Questions marked with an asterisk (*) are required. If you have any questions about the survey, please email us: PCS-Communications@pcs.hctx.net
Please provide your legal (first and last) name. If unwilling, please write N/A. *
What is your current home address? If unwilling, please write N/A. *
If unwilling to provide your address, please write your zip code. If you have provided your home address, please write N/A. *
How long have you lived at your current address? *

Less than 1 year 1 to 5 years 6 to 10 years More than 10 years
How concerned are you about hazardous waste pollution in your community? *

Not at all concerned Slightly concerned Moderately concerned Very concerned
How concerned are you about water pollution in your community? *

Not at all concerned Slightly concerned Moderately concerned Very concerned
How concerned are you about air pollution in your community? *

Not at all concerned Slightly concerned Moderately concerned Very concerned
How concerned are you about solid waste pollution in your community? *

Not at all concerned Slightly concerned Moderately concerned Very concerned
If concerned about other types of pollution, please specify.
Do you live near a contaminated site or a Superfund site? *

Yes No I don't know
If you answered Yes for the previous question, please state the name of the Superfund site.
Do you know if near your home is a factory/industry/facility that uses toxic chemicals? *

Yes No I don't know
Do you think that the exposure to chemicals from factory/industry/facility could make you and your family sick? *

Yes No I don't know
If your previous answer is Yes, have you or anyone in your household been diagnosed with an illness that includes cancer, asthma, respiratory disease other than asthma, ischemic heart disease or stroke?

Yes No I don't know
Regarding the previous question, please identify the illness you, or anyone in your household, have been diagnosed.

Cancer Asthma Respiratory disease other than asthma Ischemic heart disease Stroke
Regarding the previous question, please list other health conditions you or members of your household have been diagnosed with, or write N/A if no health conditions are present.
How do you or your family come in contact with chemicals, in a way that allows enough of them into the body to result in illness? Please choose all options that apply. *

Through water supplies Groundwater Reservoir water Private well Public well Through ambient air Through soil Landfill Through food Other
If a factory/industry/facility is located near your home, what type is it? Please select all that apply to facilities near you. *

Adhesives Aeronautics & Space Aerospace & Aviation Airport Chemicals' manufacturing Concrete batch plant Construction Detergents Digital Technology Electronics Engineering, and nanotechnology Food & Beverages Information technology Iron and steel Leather Lubricants Metals and related (lead, mercury, chromium, nickel, etc.) Motor vehicles Paint and coating Paper Pesticides and fertilizers Petroleum and petroleum products Pharmaceutical Plastics Port Sugar manufacturing and related Textiles None Other
If you checked a box other than None in the previous question, please write the name of the factory/industry/facility.
If you believe that your area is contaminated, what is your perception for that belief? *

Taste of water Water smell Air smell Observed health effects Other
If you chose “Air Smell” in the previous question, please choose when applicable, in the following types of odors:

I did not choose "Air Smell" Strong odor Fruity Sweet, aromatic Sharp, acrid Gasoline-like Solvent-like Disagreeable odor Naturally pungent odor Rotten egg smell Smell associated with paint thinners Other
How frequently do you perceive signs of pollution (smell for example)? *

Daily 1-3 times per week 5 days a week Once a month Twice a month Other

Have you or someone in your home had some of the following health effects and approximate frequency? Please check a column for all health effects that apply to you or someone in your household. *

	Never	Every day	3-8 times a month	Twice a month	Once a month
Shortness of breath
Asthma
Chronic obstructive pulmonary disease (COPD)
Coughing
Sneezing
Dizziness
Dryness and/or irritation of the eyes
Dryness and/or irritation of the nose
Dryness and/or irritation of the throat
Dryness and/or irritation of the skin
Eczema
Fatigue
Flu-like symptoms
Headache
Allergies
Nausea
Other

If you chose a frequency for the "Other" category in the previous question, please identify the health effect experienced.
Have you been diagnosed with a chronic health condition such as diabetes, cancer, high blood pressure, cardio vascular disease (CVD), chronic obstructive pulmonary disease (COPD) or asthma? *

Yes No
If you answered Yes to the previous question, please select your diagnosis.

Diabetes Cancer High blood pressure Cardio vascular disease (CVD) Chronic obstructive pulmonary disease (COPD) Asthma
Do you think that you can contribute to improve the quality of life of your area, regarding the exposure to toxic chemicals and their potential health consequences? *

Yes No I don't know
How do you think that you can contribute to improve the quality of life of your area, regarding the exposure to toxic chemicals and their potential health consequences? *
Is there any activity in your community addressed to improve that life-quality? *

Yes No I don't know
If YES, please explain briefly what the community is doing.
Have you and/or some relative, had some type of cancer that could be related with the chemical exposure? *

Yes No I don't know
If you answered Yes to the previous question, please specify type of cancer.
Do you have any familiarity with Harris County Pollution Control Services Department (PCS)? *

Yes No
Are you aware that you can make any complaint related to potential harmful exposures to chemical pollutants, in your area, to the PCS? *

Yes No
Letter of Consent
Should be Empty: