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 email address if you would like to be added to our mailing list. If unwilling to provide, please write N/A. *
Please provide your household zip code. *
Please provide your work zip code.*
At which location are you most concerned about regarding pollution?*

HomeWorkBoth
How long have you lived/worked at the location you have concerns with?*

Less than 1 year1 to 5 years6 to 10 yearsMore than 10 years
Are you concerned about any of the following environmental issues in your community/work? Select all that apply.*

Air pollutionWater pollutionHazardous solid waste pollutionNone of the above
Do you perceive any sources of pollution near your home/work? Select all that apply.*

Air pollutionWater pollutionHazardous solid waste pollutionNone of the above
Have you or someone in your household been diagnosed with any of the following illness? Select all that apply.*

No one in my household has been diagnosed with an illnessCancerAsthmaRespiratory diseaseHeart diseaseOther
Please select any health conditions that you or a member of your household have experienced without reasonable cause. Select all that apply.*

No one in my household is experiencing a health condition without reasonable causeDizzinessNauseaTirednessIrritation of eyes and noseSore throatCoughingDifficulty breathingWheezingOther
Do you have any familiarity with Harris County Pollution Control Services Department (PCS)?*

YesNo
Are you aware that you can make any complaint related to potential harmful exposures to chemical pollutants, in your area, to the PCS?*

YesNo
Letter of Consent
Should be Empty: