Telling the Stories Health Questionnaire

Health Questionnaire

Telling the Stories: Health Impacts in the Fore River Basin
Please read the following information completely.

We who live in the Fore River Basin are keenly aware of the toxic legacy of the industrialization of our coastal home. We have heard story after story of cancers, asthma, and autoimmune disorders--many of these illnesses familial and generational.

FRRACS is undertaking a project to document the health stories of those who have lived with this issue. We will be working to collect your stories by video, by recordings, and by writing. We will make a short documentary film that will be premiered at a very special meeting in the fall.

This project is NOT a research study, is not scientific, and is not intended to be a comprehensive assessment of health conditions in the Fore River Basin. The Fore River Basin is an overburdened community with high levels of pollution. This project aims to document and share the stories of people who have been impacted by the toxic history and ongoing pollution in the Fore River Basin. Leading public health experts are testifying to the Mass. Department of Environmental Protection that a new compressor station in the Fore River Basin would further exacerbate the current levels of pollution and would have a negative impact of the health of nearby communities.

This questionnaire is completely voluntary and will remain anonymous (unless you choose to share your story on video). By filling out this questionnaire, you give consent for your information to be used as part of our storytelling project. Your information will not be shared beyond the scope of the documentary project and will not be shared with any other groups. FRRACS will store your questionnaire securely.

When filling out the questionnaire, only answer as much as you are comfortable with. We know that this information is very personal and your privacy is very important to us. Our intention is to illustrate the extent to which people have been impacted, so we appreciate anything that you are willing to share.

This project is being led by FRRACS (Fore River Residents Against the Compressor Station). Funding for the project is provided by a grant from The Island Foundation. If you have any questions, comments, or concerns, please let us know. You can contact us via email at frracshealth@gmail.com.

Background Information
Age
Current Address

Street

Street Address Line 2

CityHow long

Postal / Zip Code
How long have you lived at your current address?
Previous Address (Street and City/Town)

Street

Street Address Line 2

CityHow long di

Postal / Zip Code
How long did you live at your previous address?
What is your current occupation? How long have you worked there?
What was your previous occupation? How long did you work there?
Have you ever worked in an industrial factory (i.e. power plant, manufacturing facility, etc.) and what was your position?
If you've worked at an industrial factory, how long did you work there?
How many people do you live with?
If you live with other people, what is their relation to you (friend, family member, etc.)?
What are their occupations?

Would you like to share your story on camera? If yes, please provide us with your contact information so that we can set up an interview. *Please note that although we would like to give everyone the opportunity to share their story on camera, we will not be able to set up interviews with every individual.*
Name

First Name
Email
example@example.com
Phone Number

Area CodePhone Number

If you submit a questionnaire, we may use your information anecdotally in the documentary. Your information will remain anonymous unless you choose to be on camera. For example, we may list how many cancers of a certain type were reported in one neighborhood. If you are not comfortable with this, we kindly ask that you do not submit the questionnaire.

If you have any questions, comments, or concerns, please contact us via email at frracshealth@gmail.com.
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