-------
A-8
A-33
73 74
A-3t
75
ID
DK
5 6
A-35
10
A-36
11
A-37
12
-------
A-38 What do you think it tastes like?
01 I"! Sweet
02 r~l Sour
03 r~J Bitter
04 Q Salty
05 J^] Mineral water
06 [""I Chlorine
07 Q Swanky
[""I Other (specify)
A-9
A-39 Do you ever get noticeable changes in
the taste of the water?
0 I I No (If Respondent also aneaered "So taste" to
1—' Q A-37. then ao to 0 A-44)
1 D
Q A-37, then go to Q A-44)
Yes
A-40 (Show card 10) How much of the time
would you say you notice a taste?
4 All of the tine
3 r~"| Most of the time
2 I I Some of the time
1 [ | Hardly ever
A-41 What do you think is the major reason
for the taste of the water?
INTERVIEWER ISSTRUCTIOS: Record the response, then check
the most applicable category.
I I A problem within the house (plumbing, etc.)
01
02 |[ A breakdown in the physical facilities of the
— water system outside the house
03 II Inadequacy of the physical facilities of the
'—' system (pipes too small, storage capacity too
small, etc.)
04 I I Mismanagement of the system (ill-trained operators,
^~* Inattention, etc.)
05 f~j Deliberate or planned activities (additives, etc.)
-8
r~\ Don't know
II Other
INTERVIEWER ISSTRUCTIOS: If Respondent mentioned any seasonal factors, check "yes" to Q A-42, then go to
Q A-43.
A-42 Do you also notice any seasonal
variations in the taste of the water?
0 I Ho (Go to Q A-44)
1 Q Yes
-------
A-9
A-38
13
A-39
15
A-UO
16
A-41
17 18
A-U2
19
-------
A-43 (Sham cord 12) Which of these categories
would you say best describes the taste
of the water for each of the four
seasons?
A-10
012
No taste Slight taste Strong taste
Spring
Summer
Fall
Winter
A-44 (Shout card 11) Please indicate which one
of these categories'best describes how
you feel about the taste of the water?
5 | | I like it a great deal; it is very pleasing to me
4 r~\ I like it
3 | [ It is alright. I am used to it and I really
don't notice or think about it much
2 I""] I don't like it
1 r~j I dislike it very much and I really wish I
— could change it
TEMPERATURE
A-45 These next few questions relate to the
temperature of the water. What would
you say that the temperature of the
water in the past year has usually
been—cold, cool or warm?
3 rn
2 I""] Cool
Warm
D
A.-46 Do you ever get any noticeable changes
in the temperature of the water?
NO
Yes
A-47 (Shoa aard 10) How often would you say
the water has this usual temperature?
1 ([ All of the time
2 r~\ Host of the time
3 FI Some of the time
4 | | Hardly ever
A-48 What do you think is the major reason
for the temperature of the water?
INTERVIEWER INSTRUCTION: Record the response, -then
check the most applicable category.
01 I I Natural temperature of the water
02 | [ Pipes are too close to the surface of the ground
03 (""] Pipes pass too close to a heating device (furnace,
— heater, etc.)
0* II Storage tank is in direct sunlight or otherwise
1—' heated
05 Q Seasonal factors (Go to Q A-50)
-8 II Don't know
II Other
_ _^______
-------
A-10
A-13
20
21
22
23
A-Ut
A-15
25
A-16
26
A-t7
27
A-U8
28 29
-------
A-49 Do you also notice seasonal
variation in the temperature
of the water?
A-11
No (Go to Q A-Bl)
Yes
A-50 (Shoa card 13) Which one of these cate-
gories would you say best describes
the temperature of the water for
each of the four seasons?
1
Cold
2
Cool
3
Warm
Spring
Summer
Fall
Winter
A-51 (Shoa eard 11) Which one of these
categories would you say best
describes how you feel about the temper -
ature of the water?
5 | [ 1 like it a great deal; it is very pleasing to me
t Qj| I like it
3 | | It is alright. I am used to it and I really don't
notice or think about it much
D
I don't like it
1 | [ I dislike it very much and I really wish I could
^"^ change it
CLEARNESS-CLOUDINESS
A-52 The next three sets of questions need
some explanation. The first group
deals with how clear the water looks.
The second group deals with the color
of the water, and the third asks about
sediment, or particles that might be in
the water. It can be hard sometimes
to keep these things straight, so let
me explain. Water can sometimes be
cloudy, which makes it harder to see
through. If it is cloudy, it may have
some sort of color too. But even clear
water can sometimes have color, like a
grayish or yellowish cast, for example.
Also, regardless of whether the water
is cloudy or has color, it can have
sediment or particles in it. In a
glass of water the sediment would
settle to the bottom, like sand or
something. OK? Now we'll start with
how clear or cloudy the water looks.
(Shoa oard 14) For the past year, would
you say the water has usually been
cloudy or clear?
1 Clear
2 r~\ Slightly cloudy
3 II Very cloudy
A-53 Do you ever get noticeable changes in
the clearness or cloudiness of the
water?
[ | So (If Respondent also answered1 "clear" to
— Q A-SS, then go to Q A-68.)
Yea
A-54 (Shoa oard 10) How often would you say
the cloudiness occurs?
H \\ All of the time
3 ["""I Most of the time
2 |^| Some of the time
1 II Hardly ever
-------
A-11
A-49
30
A-50
A-51
~35~
A-52
36
A-53
-37-
A-51
-------
A-55 What would you say is the major reason
for the cloudiness?
A-12
IJ.ffKKVJ.KwEK jaSTKUVTJ.ua: aeaofa tne reeponse, then oneoK.
the most applicable oategory.
01. I I A problem within the house (plumbing, etc.)
02 d
A breakdown In the physical facilities of the
water system outside the house
03
| |
OU
05 Q
- D
Inadequacy of the physical facilities of the
system (pipes too small, storage capacity too
small, etc.)
Mismanagement of the system (ill-trained operators,
inattention, etc.)
Deliberate or planned activities (additives, etc.)
Don't know
Other
ISTERVIEi/ER INSTRUCTION: If Reepcmdent mentioned any sea-
sonal faotore, ohaok "yee" in Q A-56, then go to Q A-S7.
A-56 Do you also notice seasonal variations
in the clearness of cloudiness of the
water?
Ho (So to Q A-S8)
V..
A-S7 (Shoo eard 14) Which of these categories
do you think best describes the clear-
ness or cloudiness of the water for each
of the four seasons?
Spring
Tall
Winter
1
Clear
Slightly cloudy
Very cloudy
A-S8 (Show oard 21) Which one of these cate-
gories would you say best describes
how you feel about how clear or
cloudy the water is?
5 II I like it a great deal; it Is very pleasing to me
t Q I like It
3 [""I It is alright. I am used to It and I really don't
notice or think about it much
D
I don't like it
1 | | I dislike it very much and I really wish I could
—change it
COLOR
A-59 Mow, we're into the second set of
questions dealing with the color of
water. Would you say the water is usually
very colored or slightly colored or has
no color at all?
0 Ho color (Go to Q A-61)
1 Q Slightly colored
2 |~[ Very colored
-------
A-12
A-55
39 HO
A-56
A-57
1*2
43
44
45
A-58
A-59
-------
A-60 What is the usual color?
ol I I Bed
02 Q] Orange
03 Q Black
Ot j~"] Yellow
05 r~] Hhite
06 Q Grey
07 Q Brown
08 Q Blue
09 [~~j Green
Other (specify)
A-13
A-61 Do you ever get noticeable changes in
the color of the water?
0 I UNO (If Respondent also answered "So aolor" to
1—" Q A-S9, then go to Q A-66.)
D
Yes
A-6 2 (Shoa card 10) About how much of the
time would you say the water has color?
t I | All of the tine
3 j~] Most of the time
2 | | Some of the time
1 | | Hardly ever
A-63 What do you think is the major reason
for the color of the water?
INTERVIEWER INSTRUCTION: Record the response, then aheak
the most applicable category.
01
02
03
0<4
05
-8
a
a
a
a
a
a
a
A problem within the house (plumbing, etc.)
A breakdown in the physical facilities of the water
system outside the house
Inadequacy of the physical facilities of the
system (pipes too small, storage capacity too
snail, etc.)
Mismanagement of the system (ill-trained operators,
inattention, etc.)
Deliberate or planned activities (additives, etc.)
Don't know
Other
ISTBRVIEWER IHSTRUCTIOB: If Seepondmt mentioned any seasonal factors, cheek "yes" in Q A-64, then go to
Q A-SS.
A-64 Do you also notice any seasonal
variations in the color of the water?
0 || Uo (Go to Q A-66)
1 Yes
-------
A-13
A-60
A-61
A-62
A-63
48 49
50
51
52 53
A-61
-------
A-65 (Shew aard IS) Which category would you
say best describes the color of the
water for each of the four seasons?
Spring
Summer
Fall
Winter
A-14
012
No color Slightly colored Very colored
A-66 (Show eard 11) Which one of these
categories would you say best describes
how you feel about the color of the
water?
5 [ | I like It a great deal; It Is very pleasing to me
H f~~| I like It
3 [ ] It is alright. I am used to it and I really don't
^~^ notice or think about it much
I don't like it
D
[ | I dislike it very much and I really wish I could
— change it
SEDIMENT OR PARTICLES
A-67 Now, I'll ask you if, in the past year,
the water has usually had any sediment
in it. (Shoo oard 16) Which of these
categories would you say describes the
water with regard to sediment or
particles?
0 [""] No sediment
1 | ] Usually no sediment
2 [ | Usually some sediment
3 | | Usually heavy sediment
A-6 8 Do you every notice any changes in the
sediment or particle content of the water?
No (If Respondent also said "No sediment", in
Q A-67, then go to Q A-73.)
D
Yes
A-69 (Show oard 10) How often would you say
the water has sediment or particles?
t I"! All of the time
3 r~~\ Most of the time
2 [""1 Some of the time
1 [~ | Hardly ever
A-70 What do you think is the major reason
for the sediment in the water?
INTERVIEWER INSTRUCTION: Record the response, then
check the most applicable category.
01
02
03
INTERVIEWER INSTRUCTIONS: If Respondent men-
tioned any seasonal factors, oheak "yes" in
Q A-71, then go to Q 4-72.
05
-8
D
D
D
D
D
D
D
A problem within the house (plumbing, etc.)
A breakdown in the physical facilities of the water
system outside the house
Inadequacy of the physical facilities of the
system (pipes too small, storage capacity too
small, etc.)
Mismanagement of the system (ill-trained operators,
inattention, etc.)
Deliberate or planned activities (additives, etc.)
Don't know
Other
-------
A-14
A-65
56
57
58
A-66
A-67
A-68
A-69
59
60
61
62
A-70
63 64
-------
A-71 Do you also notice seasonal variations
in the sediment or particle content
of the water?
Ho (do to Q A-73)
Yes
A-15
A-72 'Shew card 16) Which of these categories
do you think best describes the
sediment content of the water for each
of the four seasons in the last year?
No
Sediment
Spring
Fall
Winter
123
Usually Usually Usually
No Some Heavy
Sediment Sediment Sediment
A-73 (Show card 11) Which one of these
categories would you say best describes
how you feel about any sediment
or lack of sediment in your water?
5 I I I like it a great deal; it is very pleasing to me
H Q I like it
3 [] It is alright. I am used to it and I really don't
— think about it much
2 r~\ I don't like it
1 I I I dislike it very much and I really wish I could
1—' change it
WATER QUANTITY
A-74 Next, 1 want to ask about the amount of
water that is available to you, that
is, whether you can get enough water
for your needs. (Show card 17) For the
past year, which of these categories
would you say best describes how much
water you generally get for your house-
hold uses from your major water supply?
1 | j All the water I ever want
2 I I Usually as much water as I want
3 I I Usually not as much water as I want
[ | Never as much water as I want
A-75 Do you ever notice changes in the
amount of_ water you can get?
II No (If Respondent also ansaered "all the water I
1—' ever uant" to Q A-74, then go to Q A-80. )
D *»
A-76 (Shaa aard 10J How often does the con-
dition occur?
1 r~j All of the time
2 I""! Most of the time
3 PI Some of the tlae
"* I I Hardly ever
-------
A-15
-6T-
-66-
A-72
—69"
A-73
A-7t
A-75
A-76
72
-------
A-16
A-77 What do you think is the major reason
you don't get as much water as you
need?
the most applieable category.
Record the response, then cheek
A problem within the house (plumbing, etc.)
01
02 II A breakdown In the physical facilities of the
'—' water system outside the house
03 II Inadequacy of the physical facilities of the
'—' system (pipes too small, storage capacity too
small, etc.)
OU. I""] Mismanagement of the system (ill-trained operators,
^~^ inattention, etc.)
05 |~n Deliberate or planned activities (additives, etc.)
-8 I I Don't know
II Other
ISTERVISVER ISSTSUCITOS: If Respondent mentioned any seasonal factors, check "yea" in Q A-78, then go to
Q A-79.
A-78 Do you also notice any seasonal
variations in the amount of water you
get?
0 [~n No (Go to Q A-80)
1 I I Yes
A-79 (Shoo oord 17} Which of these categories
do you think best describes how much
water you can get for each of the four
seasons?
123 i*
All the Usually as Usually not. Never as
water 1 much water as much water much water
ever want as l' want as I want as I want
Spring
Summer
Fall
Winter
A-80 (Shoo oord 11) Which of these categories
would you say best describes how you
feel about the amount of water you can
get throughout the yearT
5 I""! I like it a great deal; it is very pleasing to
i* Q I like it
3 I I
I It is alright. I am used to It and I really don't
— ' think about it much
2 J~l I don't like it
1 I I I dislike it very much and I really wish I could
•— • change it
WATER PRESSURE |
A-81 Now, some questions about the water
pressure. (Shoo cord 18) Which of these
categories do you think best describes
the usual pressure of the water for
the last year?
01 r~j About right
12 (1 Too high
13 T~~\ Too low
14 I
-9 I
Goes up and down (fluctuates)
Not applicable—not a piped, pressurized system
(Go to C A-88)
-------
A-16
A-77
74 75
ID
DK
5 6
A-78
A-79
10
11
A-80
12
A-81
13
-------
A-S2 Do you ever notice changes in the water
pressure from what is usually is?
D
A-17
Ho (If Respondent also ansaered "About right" to
Q A-81, then go to Q A-87.)
Yes
A-83 (Show card 10) About how much of the
time in the past year was the water
pressure that way?
1 r~j All of the cine
2 I1 Most of the time
3 I1 Some of the time
4 I I Hardly ever
A-84 What do you think is the major reason
for that condition?
INTERVIEWER INSTRUCTION: Record the response, then oheok
the moat applicable category.
A problem within the house (plumbing, etc.)
01
02
03
A breakdown in the physical facilities of the water
system outside the house
Inadequacy of the physical facilities of the
<~~> system (pipes too small, storage cpacity too
small, etc.)
04 | | Mismanagement of the system (ill-trained operators,
^~^ inattention, etc.)
05 II Deliberate or planned activities (additives, etc.)
-8 [ | Don't know
II Other
INTERVIEWER INSTRUCTION: If Respondent mentioned any seasonal factors, check "yes" in Q A-8S, then go
to Q A-86.
A-85 Do you also notice seasonal
variations in the water pressure?
0 r~l No (Go to Q A-87)
A-86 (Show card 18) Which of these categories
best describes the water pressure for
each of the four seasons?
01 12 13 It
Goes up
About Too Too and
Right High Low down
Spring
Summer
Fall
Winter
A-87 (Show card 11) Which of these categories
would you say best describes how you
feel about the water pressure you have
throughout the yeart
5 I like it a great deal; it is very pleasing to me
t [""I I like it
3 II It is alright. I am used to it and I really don't
'—' think about it much
2 I""] I don't like it
1 j~"l I dislike it very much and I really wish I could
^"^ change it
-------
A-17
A-82
15
A-83
16
A-B4
A-85
A-86
20 21
-22 W
2f 25
-26- -27
A-87
28
-------
A-18
HEALTH
A-88 Okay. The next question deals with the
safety of the water. Sometimes water
affects people's health, and you may
have noticed occasional health problems
due to the water here. Would you tell
me, please, if in the past year you
think that anyone who lives here became
ill because of the water provided by the
major household water supply?
0 No
1 PI Possibly
Yes
A-89 Has it ever happened that a visitor or
guest became ill after using the
water here?
0 1 1 No (If Respondent also answered "So" to Q A-B
' — ' then go to Q A-91.)
go
Possibly
Yes
A-90 Please describe the Illness(es) and
about how many times someone was sick
from each type of illness in the past
year.
Description/Symptoms
No. of
Incidents
GENERAL PROBLEMS
A-91 We have talked about the color,
temperature, clarity and other
characteristics of the water. Do
any of these result in specific
problems or inconveniences that we
nave not discussed?
0 f~] No (Go to Q A-93)
1 Yes
A-92 What would you say are the problems or
inconveniences?
01 I1 The water is not safe to drink
02 f~l Don't get enough water
03 [ | The water is safe but not palatable
04 f | Cannot depend on the water supply
05 ["""I It is costly to treat the water
06 II Affects the laundry
07 I I Affects the flavor or appearance of food and drink
08 | | Leaves deposits
I I Other (specify)
-------
A-18
A-88
A-89
~30~
A-90
33 34
-33 35-
~~3735"
53 55"
—*S
57 U5~
A-91
49
-3T
-------
COST OF WATER |
A-19
A-93 Next we would like to learn some things
about the costs of your household
water. You may not think a lot about
how you pay for water because people
pay for their household water in a lot
of different ways. Some people get a
bill; other people have their own well
and pay to repair it or they pay for
electricity or gas to run it. Some
people don t pay money for water but
receive it in exchange for their labor
along with wages. For other people,
the cost of water is included in their
rent or mortgage payment. Now, regard-
less of how you pay for water, do you
feel that the cost of your water is in-
expensive, reasonable, expensive, or very
expensive?
0 Q Ho cost (Go to Q A-9?)
1 | [ Inexpensive
2 [ | Reasonable
3 [ | Expensive
4 I I Very expensive
8 | | Don't know
A-94 Do you think the cost of your water
has increased, decreased or remained
the same during the past year?
1 I | Decreased
2 [^1 Remained the same
3 | | Increased
A-95 (Shoa oard 19) How do you pay for the
regular use of your household water?
01 | | Receive a regular water billing
02 [""I It is included In the mortgage payment (Go to Q A-97)
03 [""I It Is included In the rent payment (Go to Q A-S?)
OH [ I It Is the cost of operating and maintaining
^~^ equipment (electricity, gas, parts, labor, etc.)
(Go to 9 A-9?)
-8 Q Don't know (Go to Q A-9?)
f~] Other (specify)
-------
A-19
A-93
A-91
52
53
A-95
54 55
-------
A-96 Do you have a recent water bill around
that I could take a look at?
A-20
0 I_J No (Go to Q A-9?)
1 I I Tes (fill in as muoh information as is available
1—' on the bill.)
A. Name of the system
Address
B. If the water bill is subsumed in a total utility bill
which is not itemized, how much Is the total bill?
$
C.
[ | Amount is for water alone
j~n Amount Includes other utilities
What other utilities does it cover?
D. Time period covered by the bill?
E. Volume of water?
F. Meter readings: to _
C. Is the bill a: 1 || flat rate
2 [ | uniform rate
3 r~[ block rate
| | step rate
Other (specify)
H. Service charge? $_
I. List the charges per number of gallons (or cubic feet)
used:
_per_
gallons
per
gallons
Per
gallons
A-97 (Shot oard 20) Let me describe a water
system and you tell me which one of
these categories best describes how your
household water supply compares to it.
Imagine a water supply that is clean.
cold, good to drink, that has good
pressure, and that is always plentiful.
How does that water supply compare to
the one in this house?
1 | | This house's water supply is. better than the one
^"^ you described
2 |~~| They are probably about the same
3 [~~| The water supply you describe is better than the
""•^ one for this house
-------
A-20
A-96
56
57
61
62
63
64
65
66
67
68
69
70 71
72 73
74 75
76 77
60
A-96
13
19
25
26
30
39
A-97
48
52
57
12
18
24
29
33
38
47
51
56
ID
DK
5 6
-------
A-98 You pay for your water by:
A-21
INTERVIEWER INSTRUCTION: Review hoa the
Respondent pay a for water—through a bill, by
maintaining a well or aiatern, labor costs,
electricity ooata, etc.
Is that right?
Now I need to ask you a question that
will help us understand if people
across the country would pay more money
for their water if they could have a
good water supply. Suppose you were
offered a supply of water like I des-
cribed a minute ago, that is good to
drink, that gives as much water as you
need for the house and so on. Think
how that kind of water supply compares
to the one you have now. How much more
would you be willing to pay each year
to have that water supply--nothing,
5% more, 10%, 25%, twice as much, or
what?
(Record relevant additions or corrmenta)
0 r~] Hilling to pay the sane
1 || Hilling to pay less
2 I""! Hilling to pay aore
HOUSING CHARACTERISTICS
A-99 Next I have a few questions concerning
your housing. How long have you lived
here?
(No. of years)
A-100 Do you own or rent this home?
Own
Rent
Other (specify)
-------
A-21
A-98
58
A-99
59 60
A-100
61
-------
A-101 (Shou oard 22) Here is a card that shows
some things people have in their homes.
Could you please tell me how many of
each one there is in this house?
(shared) (number)
A-22
niTEKVIEVER INSTRUCTION: If the household
is a multiple family duelling^ unit, then
inquire if any of mentioned items are shared
with another unit and indicate those which
are shared.
D
D
D
D
D
D
D
D
D
D
Bathtubs
Showers
Bathroom sinks
Kitchen sinks
Flush toilets
Washing machines
Dishwashers
Hot water heaters (capacity_
Swamp/evaporative coolers (for cooling
house)
Household humidifers
Other (specify)
-------
A-22
A-101
62
63
65
66
67
68
69
70
75
76
73
ID
DK
5 6
A-101
-------
DEMOGRAPHIC INFORMATION
A-23
A-102 The next group of questions asks about everyone who lives in this house on a regular basis.
Let's start with the head of the house:
B. IB that a nan/boy or woman/girl?
C. (Shew card 23) Which one of these groups best describe him/her 1
1 White (Not of Hispanic origin)
2 Black (Not of Hispanic origin)
3 Hispanic
4 American Indian or Alaskan Native
5 Asian or Pacific
Islander
D. About how old is he/she ? (If person is under Jff, then go to -item A)
E. (Shew card 24) How many years of formal eduction has he/she completed?
Elementary
123456
Jr. High and High School
7 8 9 10 11 12
College
1 2 3 4 5 6 +
(13 14 15 16 17 18 +)
F. (Shoo aard 25) Which one of these best describes him/her ?
1 Working full time
2 Working part time
3 Going to school
4 Keeping house
5 Retired
6 Unemployed
G. What kind of work does he/she usually do; what is the job called?
H. What are the main duties of the job?
I. About how many hours did he/she work at that job last week?
J. Does he/she also have another job? (If no other job, then go to Item A) What is the job called?
K. What are the main duties?
L. About how many hours did he/she work at that job last week?
M. Does he/she earn more money at the first job or the second job? (write the appropriate code # below)
0 About the same 1 First 2 Second 8 Don't know
N. INTERVIEWER INSTRUCTION: Circle this person in column A if he/she is the person being interviewed.
A. Now let's talk about the next person who lives here on a regular basis. Who would that be? (How are they
related to the head of the household?)
INTERVIEWER INSTRUCTION: When the Respondent has identified everyone in the household, count the number
you have recorded then ask if that is the correct maiber of people uho live in this household on a
regular basis. If it is not, then continue listing individuals until you have the correct number.
G (J)
H (K)
KIO
(Circle the
person inter-
viewed)
Relation to
Head of House
S3 „
4J |4 M>
u
•2
o
Job Title
Duties
Head
-------
A-23
10 11
A-102
First
Person
12
13
14 15
16 17
18
19
23 24
25
22
28
29 30
31
32
-------
B C D E F
G (J)
H (K)
(Circle the
person inter-
viewed)
Relation to K £ -H » «
Head of House tn w o <: *« a
Job Title
Duties
A- 24
-------
A-2U
33 34
35
36
37 38
39 40
A-102
Second
Person
46 47
52 53
54
55
45
51
A-102
Third
Person
56 57
58
59
60 61
62 63
64
65
69 70
71
75 76
77
78
66
74
-------
r fil H I(L)
ABCDEF G 1J) •«
1
(Circle the So 5
person inter- -o
- 1 1 *" O •
vieued) _o c o o o>
Relation to „ .§ 3 „ „ -{5 =
Head of House ^ £ £ £ £ S Job Title Duties *
p
s
A- 103 (Ask only in multiple fan
Would you please tell
number of people Chat
here, including the n
household?
p
s
p
s
p
s
lily deuelling units)
me the total (t of people)
presently live
embers of this
M
u
o
€
INCOME
A-104 Do you own or lease a farm?
No (Go to Q A-107)
Yes
A-105 What was the gross farm income last
year?
A-106 What was the net farm income for last
year?
A-107 What was the total combined income
(wages, interest, pensions, net
business profits, etc.) of everyone
in this household from non-farm
sources last year?
Time Section A Completed
A- 25
-------
ID
DK
A-25
A-103
A-104
A-105
10
A-106
17
22
A-107
23
28
-------
SECTION B
PHYSICAL FACILITIES
Time of Starting Section B
Date of Interview
mo day yr
Interviewer Name
Interviewer Number
INTERVIEWER INSTRUCTION: After obtaining the required -information from Section A, read the following statement to the
Respondent.
Before continuing with the next set of questions, which deals generally with physical facili-
ties, I would like to once again establish the type of (major) water supply serving this house-
hold. In an earlier question, you indicated that this supply is a
WATER SUPPLIES
B-l Now, of all the supplies that provide
water to this household, are there
any that you haven't told me about?
No (If the Respondent said in Section A that the
(major) supply is a uell, spring, surface mater
source or cisten, go to Q B-4; otherwise, go to
e B-IS.)
D.
D
Yes
B-2 (Show card 1} Which of these cate-
gories best describes the additional
supply or supplies?
D
D
D
D
Water system with IS or more households or that
serves more than 25 people
Well
Spring
Surface water (pond, lake, river, stream).
Cistern
Hauled
Purchased, bottled
B-3 Why does this household have the
additional supply (ies)?
D
D
D
D
D
D
D
The major supply Is sometimes of insufficient
quality to drink
The major supply is available all of the time,
but does not produce a sufficient quantity of
water
The major supply is sometimes unavailable
(interrupted service)
The different supplies serve different parts of
the house
One supply is too expensive
A newer system was installed without removing
the old system
Don't know
Other (specify) ___^
-------
B-1
ID
DK
B-1
B-2
5 6
10
11
12
13
14
B-3
15
16
—24-
-------
L INTERVIEWER INSTRUCTION: If the major supply of household water is a water system with 15 or more
connections or that serves more than 25 people, then go to Q B-15.
B-2
B-4 Concerning the (major) water supply again,
what is the approximate distance between
the building and the point at which the
water is withdrawn?
(Specify distance in units used
by the respondent, i.e., meters,
feet, yards, or miles)
-8
n
Don't know
WELLS |
B-5
ISTERVTEWER INSTRUCTION: Ask this set of questions only if the (major) supply of water is a well.
this supply is a aistern, go to Q B-12. Ofnervn.se, go to Q B-15.
The next few questions will be about
the well that serves as this house-
hold" s (major) water supply. Ini-
tially, I need to know how long ago
the well was last modified. A modi-
fication includes such activities as
increasing the well's depth, instal-
ling or replacing its casing, or any
other type of major improvement or
change. If the well hasn't been
altered, I need to know how long ago
it was put in. Could you provide
me with either piece of information?
Don't know
(# of years)
B-6 Sometimes, when a well is dug or
improvements are made to it, a permit
is necessary before work can begin, or
before the well can be used. (Show aard 26)
Have you had to obtain a permit or
approval for any of these?
No (Go to Q B-8)
Q Well siting
f~n Well sinking
II Using the well
I I Don't know (Go to Q B-8)
[~\ Other (specify)
B-7 Who issued the permit or approval?
State agency
(Name)
County agency
(Name)
II Local agency (city, town, village)
(Name)
[ [ Land owner
r~j Don't know
II Other (specify)
-------
B-2
B-4
25
28
B-5
29 30
B-6
B-7
31
32
33
35
36
37
38
39
40
"42
45
-------
B-8 Could you please tell me the approximate
depth of the well?
B-3
(Specify depth in units used
by the respondent, i.e., meters,
feet, yards, or miles)
B-9 How was the well put in? Was it dug,
bored, drilled, driven, jetted, or
installed in some other way?
1 | Dug (Go to Q 3-15)
2 Q Bored
3 Q Drilled
4 £^ Driven
5 [ | Jetted
8 j"~j Don't know
Other (specify)
B-10 What is the diameter of the
well casing?
(I of inches)
-8
D
Don't know
B-ll Is the head of the well grouted?
\IHTERVIEWER INSTRUCTION: Go to 9 B-1S,
No
Yes
Don't know
CISTERNS 1
I INTERVIEWER INSTRUCTION: Aek thie set of questions only if the (major) supply of water is a oiatern. \
B-12 Does the cistern have a manual device,
an automatic device, or no device for
preventing first water from entering it?
0 No device
1 [""I Manual
2 II Automatic
8 rn Don't know
B-13 Does the cistern have a cleaning drain?
NO
D
D ¥es
D
Don't know
B-14 (Shew oofd 27) Which of these best
describes the cistern catchment area?
1 | | Roof top
2 I I Ground surface
3 I I Both roof and ground
8 I I Don't know
II Other (specify)
-------
B-3
B-8
48
50
B-9
51
B-10
B-11
55
—
B-13
57
B-14
-------
WATER SUPPLY SYSTEM BREAKDOWNS
B-4
B-15 Occasionally, people have difficulties
with their water supply systems because
of problems with the equipment. Pipes
sometimes break and pumps stop operating.
During the past year, were there any
breakdowns in the sypply system such
that you could not get water?
00
[""I No (Go to Q B-19)
D ¥es
(.t of breakdowns)
B-16 How many of these breakdowns occurred
inside the household/building and how
many occurred outside?
(Number)
D
D
D
Inside household
Outside household
Don't know
B-17 For both categories of breakdowns,
inside the household/building or out-
side the household/building, how many
breakdowns lasted for more than six
hours?
(Number)
Inside household
Outside household
D
D"
D
D
D
D
Don't know
B-18 When a breakdown occurs, what do you
or the other members of the household
usually do to get water?
Wait
Repair system
Borrow from neighbors
Use another supply here at the building
Buy water or some other liquid
Don't know
Other (specify)
WASTEWATER
SYSTEM]
B-19 I would now like to ask you a few ques-
ions about this household's/building's
wastewater disposal system. What kind
of system is it?
01 I I Wastewater runs into a pond, lake, or
stream
02 [ | Wastewater runs into a sewage lagoon
03 || Septic tank
Oi* [~~j Aerobic tank
05 |] Cesspool
06 II Composting or biological disposal syste
07 Q Chemical toilet
08 j| Incineration
09 Q Privy
10 | | Public sewage system
-8 [~1 Don't know
I""! Other (specify)
-------
B-U
B-15
B-16
B-17
59 60
61 62
63
65 66
67 68
B-18
69
70
73
76
ID
DK
B-19
-------
B-20 ' During the past year, were there any
breakdowns in the disposal system(s) so
you couldn't use it/them? How many?
.00 I I No (Fill in information after Q 5-22, then go
1—' to Section C)
B-5
D
Yes
of breakdowns)
B-21 Do you know why the breakdown(s)
occurred?
II Septic tanks, cesspool or other disposal device
became inoperative
[ [ Breakdown in household facilities (pipes, toilets,
— etc.)
| | Water was unavailable
| | The public sewage disposal system was inoperative
| | Don't know
(specify)
B-22 Could you please tell me how many of
these breakdowns lasted for more than
6 hours?
\IHTERVIEUER INSTRUCTION: Go to Section C I
D
Don't know
(I of breakdowns)
Time Section B completed
INTERVIEWER—Did you have to change respondents
for Section B?
No
Yes
-------
B-5
B-20
—rr
B-21
B-22
Intrvr
—2T
-------
SECTION C
WATER QUALITY ASSAY
Time of Starting Section C
Date of Interview /
Interviewer Name
Interviewer Number
mo day yr
INTERVIEWER INSTRUCTION: Read the following to the Respondent:
An important part of the information I need concerns the actual physical quality of the household water.
Regarding this, I have several questions about contamination, history of water tests, and whether or not
the water supply system includes such devices as a pressure tank, water softener, or chlorinator. Following
these questions, I need to take some specimens of the water for the laboratory assay (the process of doing
the analysis on water).
CONTAMINATION
C-l (Show card 28) In the past year do you
think the household water has been subject
to contamination from any of these?
D
n
n
n
n
n
n
n
n
n
None (Go to Q C-l)
Septic tank or cesspool
Privy (outhouse)
Animal waste
Fuel tank
Industrial waste
Agricultural fertilizer
Biocides (herbicides or pesticides)
Highway salt
Flooding
Mining sludge
Naturally occurring contaminants
Other (specify)
C-2 What action, if any, did you take to
correct this problem?
[ | Do nothing
[ | Remove the source of contamination
I I Contact the party responsible for the contamination
I I Contact legal authorities
f~~| Contact the landlord or property owner
I I Install some sort of protection from the contamination
[""I Bring legal suit
II Go to a new water supply
I I Other (specify)
-------
C-1
ID
DK
5 6
C-1
11
12
13
15
16
17
18
19
20
21
22
C-2
23
25
26
27
28
29
30
31
32
33
34
-------
WATER TEST HISTORY
C-2
C-3 For various reasons your household water
may have been tested at one time or
another. That is, a water specimen
may have been collected and sent to a
laboratory where it was examined by
qualified personnel using standard
laboratory procedures. Has your
household water ever been tested in
that manner?
0 r~j Ho (Go to d C-10)
1 II Yes
8 I1 Don't know (Go to Q C-10)
C-4 How many times has it been tested
while you have lived here?
(Write in the number)
C-5 When was the water last tested?
(month and year)
no yr
-8 [ [ Don't know
C-6 Why was the last test made?
01 I I Water system was newly installed
02 1 I The house was sold
03 I 1 Someone became ill
04 I I To check the water after some natural disaster or
'—' catastrophe (flooding, earthquake, etc.)
I I To check the water after a breakdown
I I To check the water after a system alteration
I I To determine if system alterations were needed
-8 j 1 Don't know
r~j Other (specify)
05
06
07
C-7 Who requested the test?
01 II Respondent did, or some other person in the
^•"^ household
02 ["""I Local officials
03 || state officials
Federal officials
Bank or someone interested in purchasing the
property
0<> I—I
05 J-]
06 [ | Contractor
07 II Standard procedure for the facility
-8 | [ Don't know
("I Other (specify)
-------
C-2
c-3
35
C-H
36 37
C-5
38 39
40 41
C-6
42 43
C-7
44 45
-------
C-3
-8 Was the last test a chemical test, a
bacteriological test, both, or what?
1 Chemical
2 II Bacteriological
3 r~] Both
8 r~"l Don't know
Other (specify)
C-9 What were the results of the test?
1 D
2 D
8 D
• D
D
01 Q
02 rn
03 rn
04 Q
os rn
oe r~i
o? rn
os rn
09 D
10 r~\
" D
w d
«D
16 n
- D
-9
D
Bacteriological Results
Acceptable levels of bacteria
Unacceptable levels of bacteria
Don't know
Not applicable
Chemical Results
All chemical constituents were at an acceptable
level
High levels of iron
High levels of sulphur
Unacceptable levels of arsenic
Unacceptable levels of barium
Unacceptable levels of cadmium
Unacceptable levels of calcium
Unacceptable levels of chromium
Unacceptable levels of fluoride
Unacceptable levels of lead
Unacceptable levels of selenium
Unacceptable levels of silver
Unacceptable levels of magnesium
Unacceptable levels of manganese
Unacceptable levels of mercury
Unacceptable levels of nitrate
Unacceptable levels of sodium
Unacceptable turbidity
Don't know
Not applicable
Other (specify)
-------
C-3
C-8
C-9
47
50
51
52
53
—54-
—5T
57
58
59
60
61
62
63
-------
WATER
SPECIMEN |
u-f
INTERVIEWER INSTRUCTION: Read the following to the respondent: "I have some containers I need to
fill with water. Hay I now collect some water from the kitchen faucet?"
C-10
C-ll
Record the date. / /
mo day yr
Record the time of day (check the correct . TIME OF DAY
time to the nearest hour) and record the time . — .
zone. 01 | | 1:00 am 13 | |
02 Q 2:00 am 14 | |
03 r~j 3:00 am 15 V~\
04 I 1 4:00 am 16 | |
05 1 1 5:00 am 17 [~~j
06 I — I 6:00 am 18 [ 1
07 I — I 7:00 am 19 1 1
08 [""I 8:00 am 20 [""]
09 r~j 9:00 am 21 [~~J
10 [""I 10:00 am 22 [ |
11 [""I 11:00 am 23 I ]
12 Q 12:00 noon 24 1 1
TIME ZONE
1 1 1 Eastern
2 1 1 Central
3 1 I Mountain
4 [""I Pacific
1:00 pm
2:00 pm
3:00 pm
4:00 pm
5:00 pm
6:00 pm
7:00 pm
8:00 pm
9:00 pm
10:00 pm
11:00 pm
12:00 midnight
INTERVIEWER INSTRUCTION: Collect all specimens from the cold water faucet. Turn the faucet to the
desired setting and do not adjust. Don^t begin by running the cold water for any time period longer
than would be considered normal for getting a drink of water. Put on the rubber gloves. Make sure
to place the correct chemicals in the proper containers. If, for any reason, a chemical is placed
in the wrong container, remove the label and tie it on a new, spare container which is identical in
sise and additive (where appropriate) to the container being discarded. Return the discarded con-
tainer to your supervisor. Hake sure all identification labels correspond to: (1) the number of
the sampled household and (2) the number representing the order in which the sample specimen was
taken. Cap each container firmly, but not so tight that leaks are caused. Do each of the following
items in order and check each as it is completed.
C-12
C-13
C-14
Take the water temperature. (Turn on the tap,
let the water flow over the thermometer bulb for temperature (degrees Centigrade)
30 seconds, then record the reading.)
Fill the one pint container labeled | | Step C-13 completed
"#1" (Microbiological) with water.
Tightly cap and set aside. Check the
box when completed. (Thiosulfate should
already be present in the container as
a preservative . )
Fill the one quart cubitainer labeled 1 1 Step C-14 completed
"#2" (General Physical and Chemical) ' — '
with water. Tightly cap and set aside.
Check box when completed. (There is
no preservative for this container.)
-------
C-4
C-10
C-11
65 66
67 68
69 70
71 72
73
C-12
C-13
75
76
C-1U
77
-------
C-15 Break the small ampule labeled
"Nitric Acid." Pour the contents
into the one quart cubitainer labeled
"#3" (Metil?) 7 Discard the broken
ampule in the sack provided. Fill
container #3 with water, tightly cap
and set aside. Check the box when
completed.
j~~j Step C-15 completed
C-5
C-16 Break the ampule labeled Mercuric Chloride
Pour the contents into tne
one quart cubitainer labeled "#4"
(Nitrates). Discard the broken ampule
in the sack provided. Fill container
#4 with water, tightly cap and set
aside. Check the box when completed.
[ [ Step C-16 completed
C-17 Fill a one quart glass container
labeled""^'1 (Pesticides and Herbicides)
with water. Tightly cap and set aside.
Check the box when completed. (There
is no preservative for this container.)
Step C-17 completed
C-18 Fill the one quart glass container which
has a teflon-lined cap labeled "#6'!
(Pesticides and Herbicides) with water.
Tightly cap and set aside. Check the
box when completed. (There is no pre-
servative for this container.)
I"""] Step C-18 completed
C-19 Break the large ampule labeled "Nitric
Acid." Pour contents into the one
gallon
logical.
the sack provided. Fill container #7
with water, tightly cap and set aside.
Check the box when completed.
Step C-19 completed
;allon cubitainer labeled "#7" TSadio-
ogical). Discard the broken ampule_in
C-20 Turn the water off. Put the pressure
gauge in place. Turn on the cold water
tap, full force. Read and record the
pressure.
_t of pounds of pressure
[ | Not applicable (not a pressurized system).
C-21 Record the effective volume of the
pressure tank. Close all water taps.
Allow the pump to run until the pressure
tank has reached full pressure and the
?ump stops. Connect the hose to the
aucet and fill the bucket provided to
the top level marked on the bucket.
Turn off the faucet. Empty the bucket
and repeat the procedure. When the
pump comes on, turn the water off.
Record the number of times the bucket
was filled and the number of gallons
in the bucket the last time it was
filled, when the pump engaged.
Number of times the bucket was filled
and emptied before the pump engaged.
Fraction of a bucket (to the nearest
gallon)
[ | Doable to monitor the pump
| | Unable to perform the measurement
(Explain)
I 1 No pressure tank
~n Not a pressurized system
-------
C-5
C-15
78
C-16
ID
DK
C-17
C-18
C-19
C-20
C-21
-------
PHYSICAL INSPECTION
C-6
INTERVIEWER INSTRUCTION: The next too questions should be asked of the respondent, but if he/she is
unable to provide the information, then complete them as adequately as possible according to your
observations of the facilities during the physical inspection. If you fill in any responses by your
observations, label them as your observations in the left margin.
C-22
(Show card 29} Do you. know how many of
each of these devices are connected to
this building's/household's major water
supply system?
II None of the devices
| [ Don't know
(Sumber)
Pressure tanks (volume In gallons
Water pimps (capacity In gallons per minute
Storage tanks (volume in gallons
(not hot water heaters)
Softeners
Chlorlnators
Settling tanks
Phosphate feeders
Oxidation filters
Activated carbon filters
Other (specify)
C-23 (Show card 30) Which one of these best
describes how water is brought into
the building/house?
01 I I Pressurized public system
02 I I Electric pump
03 I I Hand pump
04 I I Diesel'or gasoline driven pump
05 PI Windmill
06 [ | Artesian pressure
07 I""! Gravity flow
08 | [ Hand carried
09 F"] Hauled
-8 J~H Don't know
|~~| Other (specify)
-------
16
17
C-6
18
21
22
23
~25~
C-22
26
27
31
32
33
34
38
39
42
C-23
-------
INTERVIEWER INSTRUCTION: The following questions apply only to those households where the major
household water supply is on a system with 14 or feoer household connections or which serves 25 or
fewer people. Determine the following information by physical inspection at the termination of the
interview. Explain to the respondent that you would like to look at the water facilities and ask
him/her to show them to you. If physical inspection of the water facilities is not possible, then
check here I I and explain below, then ask the Respondent the physical inspection questions.
(explain)
C-7
C-24 Does the water source have an acceptable
cover for intrusion protection?
1 I j Unacceptable
2 J~"n Acceptable
8 I I Don't know (explain)
C-25 Is the water source adeuqately
maintained?
No
Yes
8 | | Don't know (explain)
C-26 Measure the distance between the
center of the well head, cistern, or
point of water withdrawal, from spring,
lake, etc., to the possible source of
contamination.
(Specify distance and unit used in determining
distance—feet, yards, meters, etc.)
Sewage disposal system
Oil or gasoline tank
Animal waste
Surface water contamination
Industrial waste
Agricultural fertilizer or runoff
Other (specify)
Not applicable
I INTERVIEWER ISSTRUCTIOS: If the major household water supply is a well, continue; otherwise go to Section D.
C-27 Is the cover of the well splash-proof? o ~"
Ho
Yes
8 j ] Don't know (explain)
Not applicable
-------
C-7
C-2U
44
C-25
C-26
46
49
52
55
61
6t
67
57
60
63
66
70
73
69
72
75
C-27
76
-------
C-28 Does the well have a pltless adapter
or a buried seal?
C-8
0 Neither
1 |~"j Fitless adapter
2 r~j Buried seal
8 [[ Don't know (explain)
9 [""I Not applicable
1 II It is in the open, uncovered
2 [ [ It is in the open, but protected from the elements
3 I I It is in a pit with a water-tight cover
4 [ [ It is in a pit with a cover which is not water-tight
5 II It is in a pit with no cover
8 [~~j Don't know (explain)
C-29 Which of these best describes the well?
9 I""] Not applicable
|I Other (specify).
C-30 Which of these best describes how
the pit drains?
1 [""I No drain
2 j [ Drains to open ground
3 I I Runs to a drainline or sewer line
8 I"""] Don't know (explain)
9 [| Not applicable
[""I Other (specify)
Time Section C completed
-------
C-8
C-28
C-29
77
78
C-30
79
-------
C-9
INTERVIEW INSTRUCTION: Write a brief description of the interview situation, the interview, and
any peculiarities or special airaumstancee that would assist in understanding the interview.
-------
SECTION D
SUPPLY SYSTEM
Time of Starting Section D
Date of Interview /
day yr
Interviewer Name
Interviewer Number
INTERVIEWER IttSTRVCTIOH: This section applies to households served try multiple connection water systems (i.e.,
provides water to two or more households). It is to be administered only to an individual Who is suffi-
ciently familiar with various aspects of the water supply system. In the case of private systems, quali-
fied respondents include the owner, manager, or operator. If the system is public, the respondent must
be the superintendent or someone familiar with the operation of the system. You are not restricted to
only one person. If several people are present, get the best response available from them.
Name of the supply system:
Address:
This information may be
available from Section A
Q A-96 Item A.
Date of interview:
SYSTEM SIZE
D-l First, I would like to ask about some
general system characteristics such as
size. Approximately how many service
connections are on the system?
(t of connections)
D-2 About what proportion of the connections
is metered?
(Percent or number)
Don't know
D-3 How many miles of lines are j.n the
system?
(Miles)
D
Don't know
D-4 What is the average daily usage?
(Gallons per day)
D Don'
t know
D-5 What is the maximum daily amount of
water the system can supply?
(Gallons per day)
Don't know
WATER SOURCES
D-6 (Show card 31) From which of the following
types of sources does the system obtain
water?
I I Ground water
I I Surface water
II Water is purchased
II Don't know
-------
D-1
ID
DK
5 6
D-1
"IT"
D-2
12 13
D-3
18
-23-
D-5
D-6
30
31
32
-------
D-7 Do you ever have any difficulties acquir-
ing water from the source(s)?
D
D
D
D
D
D
D
n
No (Go to Q D-9)
Yes (Ground water)
Yes (Surface water)
Yes (Water purchased)
D-2
D-8 What were the difficulties?
Equipment breakdowns (Same source)
Water was unavailable (Same source)
Weather problems (drought, flooding)
(Name; source)
Loss of a supply (Name source)
Contamination (Sane source)
Lack of money (Same source)
Other (Specify the difficulty and the source)
BREAKDOWNS
D-9 In the past year, have any breakdowns
occurred in the system? How many?
00 I I No (Go to Q J^-12)
[ 1 Yea
(f of breakdowns)
D-10 Of these breakdowns, how many have
resulted in an actual loss of
service to water users?
(I of breakdowns)
D-ll What were the causes of all the
breakdowns?
(f of times)
Pump breakdown
Ruptured lines
Treatment failure
Drought
Flooding
Vandalism
Other (specify)
-------
D-2
D-7
33
35
36
52
53
54
55
D-11
73 74
75 76
77 78
37
56
ID
38
57
OK
5 6
D-8
39
41
42
43
D-8
58
59
60
61
62
63
D-11
9 10
11 12
~13 15"
15 16
17 18
45
46
65
47
66
48
D-9
~68~
50
D-10
69 70
51
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WATER TREATMENT
D-3
D-12 Does the water that the system supplies
receive any treatment, and if so, what
types?
No (Go to Q D-14)
Yes (Filtration)
Yes (Chlorlnation)
Yes (Softening)
Yes (Fluorldation)
Yes (Other) (Specify)
Don't know (Go to Q D-14)
D-13 What types of treatment devices are
installed and presently operating in
the system?
None
II Oxidation filter
II Activated carbon filter
| | Softener
II Chlorinator
[""] Fluoridator
II Settling tank
D Chemical feeder unit (phosphate, lime, carbon,
etc.)
Identify chemical dispensed
| j Don't know
[""1 Other (specify)
OPERATORS
D-14 How many people work at operating this
system's equipment?
(Number)
D-15 How many of these are volunteers, paid
part-time employees, or paid full-time
employees?
(Number)
Volunteers
Paid part-time
Paid full-time
Don't know
D-16 About how many man-days per month does
it normally take to operate the system?
(Number of man-days)
-------
D-3
D-12
19
20
21
22
23
25
26
27
D-13
28
29
30
31
32
33
35
36
37
38
39
D-11
40 41
D-15
42 43
44 45
46 47
D-16
48 49
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D-17 How many operators have received special
training or schooling in the operation
of the system's equipment? (Training
other than that received on the job, such
as state training, equipment manufacturer's
workshops, Cooperative Extension, etc.)
(t of operators)
D-4
D
Don't know
SYSTEM ALTERATIONS
D-18 Have there been any major alterations
since the system was constructed? That
is, have there been any changes which
substantially increased the system's capa-
city or which improved the quality of the
water it provides?
No (INTERVIEWER INSTRUCTION: Read the.
The. next queAtionA
-------
D-M
D-17
5i 52
D-18
53
55
D-19
57
58
59
60
61
0-20
62 63
D-21
D-22
71
-73-
-------
D-23 What agencies provided the loans?
D-24 What is the interest rate?
D-25 What is the repayment period?
D-5
FnHA (Farmers' Home Administration)
years_
I I EPA (Environmental Protection Agency)
years_
[ [ HDD (Housing and Urban Development)
Z years
Department of Defense
years_
[ j EDA (Economic Development Administration)
years_
CSA (Community Services Administration)
years_
State agency (name)
years_
[ j Regional agency (name)
Don't know
Other (specify)
years_
years_
D-26 What portion of the cost was
financed through bonds?
or Z
(If 0, go to Q D-29)
I""] Don't know (Go to 9
D-27 What is the interest rate?
D-28 What is the repayment period?
(percent)
(I of years)
D-29 What portion of the cost was financed
through grants?
or Z
(If 0, go to Q D-31)
Don't know (Go to « D-31)
-------
D-5
D-23
74
75
76
77
78
79
ID
DK
5 6
D-23
10
13
-is ir
—is 5r
~W
"25
2f
~w
D-24
"28
—si sr
—sr
—57
—43-
—46
D-25
se-
2~
53 54
55 56
57 58
59 60
61 62
63 64
65 66"
17 6T
69 70
7T 7T
11
12
D-2?
ID
DK
D-28
—7T 7T~
D-29
-------
D-30 What agencies provided the grants?
n
n
n
n
n
n
n
n
n
n
D-6
FmHA (Farmers' Home Administration)
EPA (Environmental Protection Agency)
HDD (Housing and Urban Development)
Department of Defense
Bureau of Reclamation
Corps of Engineers
EDA (Economic Development Administration)
CSA (Community Services Administration)
State Agency
Regional Agency
Don't know
Other (specify)
D-31 What portion of the cost was financed $ or Z (If 0. go to
through commercial loans? Q D-33)
[^| Don't know (Go to Q D-33)
D-32 What was the interest rate? (percent)
D-33 How much of the cost was financed $ or Z
through reserve funds of the system?
[| Don't know
SYSTEM FINANCES] ^
D-34 What was the total annual revenue of $ (If 0, go to Q u-3?)
the system for last year? .-—,
[ I Don't know (Go to Q D-37)
D-35 What portion or how much of the revenue $ °r Z
is allocated to system operating and
maintenance costs? | | Don't know
D-36 What portion or how much of the revenue $ or Z
is allocated to debt retirement?
II Don't know
BACTERIOLOGICAL WATER QUALITY TESTS)
D-37 Are bacteriological tests performed on
this system's water?
0 Ho (Go to Q D-41)
i D *«
8 (~| Don't know (Go to Q D-41)
-------
D-6
D-30
12
13
14
15
16
17
18
19
20
21
22
23
25
D-36
D-37
45
48
47
D-31
26
28
D-32
29
31
D-33
32
34
D-31
35
41
D-35
42
44
-------
D-38 Who usually does the bacteriological
tests?
01 r~] Private lab
02 Q] System lab
03 | | Public Health Department
04 | | State Environmental Department
05 P] Federal lab
-8 [ | Don't know
Other (specify)
D-7
D-39 How often are the tests performed?
n
n
n
n
8D
n
Once a year or less
At least once every six months
At least once every three months
At least once every month
At least once a week
At least once a day
Don't know
Not applicable
D-40 Of the tests performed during the
past year or of the last twelve tests.
whichever is fewer, how many had
accepteble results?
(Total * of tests in the last year
if fewer than 12)
(Number of tests which passed)
CHEMICAL WATER QUALITY TESTS |
D-41 Are chemical water quality tests
performed on the system's water?
o [""I No (Go to end of interview)
8 II Don't know (Go to end of interoiea)
I / (date)
D-42 When was the last test performed?
day yr
-------
D-7
D-38
49 50
D-39
51
D-40
D-41
52 53
54 55
56
D-42
57 58
59 60
61 62
-------
D-43
fShou card 32) What were the results of the
last test for each of these constituents?
D-8
. Specific conductance
. Nitrate
. Sulfate
. Calcium
. Magnesium
. Iron
. Manganese
. Sodium
. Lead
. Turbidity
Color
. Arsenic
. Barium
• Cadmium
. Chromium
. Mercury
. Selenium
. Sliver
Fluoride
INTERVIEWER INSTRUCTION: Thank the Respondent (a) then exouae yourself. If the Respondent (a) were not
able to provide information on all of the questions, you mutt looate additional people oho are knou-
ledgeable about the system to oonplete the interview. Beoord belou the tine the interview uas completed.
Time Section D completed
-------
D-8
ID
DK
D-43
5 6
lank
10
lank
13
15
lank
17
18
19
lank
22
23
24
Blank
29
30
Blank
28
34
35
36
Blank
41
42
Blank
47
40
46
48
Blank
52
51
53
Blank
58
57
59
Blank
63
64 65
62
ID
DK
10
Blank
14
D-43
5 6
lank
13
15
Blank
20
21
Blank
26
27
Blank
32
33
Blank
38
39
Blank
43
19
25
31
37
42
44
Blank
48
49
50
52
-------
D-9
ISTSRVISH ISSTBUCTION: Write a brief description of the interview situation, the interview, and any
peculiarities of special circumstances that would assist in understanding the interview.
-------
SECTION E
NON-INTERVIEW DISPOSITION
Time of Starting Section E
Interviewer Name
Date of Interview / /
'mo day yr
E-l Which of these categories best portrays 01 1 I
the reason an interview was not obtained "— '
for this household
02 [-J
03 n
04 n
05 n
06 []
07 Q
08 Q
09 Q
10 D
D
ESTIMATED DEMOGRAPHIC CHARACTERISTICS 1
E-2 Do you think the probable respond- l [__j
ent owns or rents the household unit? ( (
8D
Interviewer Number
Household unit was not found. (Listing of units
indicated a household unit was present when it
wasn't.
INTERVIEWER INSTRUCTION: Contact supervisor for
instructions.
Household unit no longer exists. (Unit was torn
down, burned, washed away by high water, etc.)
Household is inaccessible (Natural catastrophe,
hazardous conditions, etc., prevent interviewing)
Address is not a household unit. (Commercial
property, religious, civic, fraternal meeting
place, etc.)
INTERVIEWER INSTRUCTION: Contact supervisor for
instructions.
Household is not eligible for inclusion in this
study. (Located on a military reservation, in a
city of over 2500, or is an institutional setting.)
INTERVIEWER INSTRUCTION: Contact supervisor for
instructions.
Household unit vacant.
No one at hone. (Household unit appears to be
lived in but no one has been contacted after three
calls.)
Respondent is absent. (Someone is at the house-
hold but eligible respondent has been absent on
each of the three calls.)
Respondents are Incapable or unable to respond.
(Respondent is illiterate, doesn't speak the
language and no interpreter is available. Respon-
dent is drunk on all calls. Acute illness pre-
vents respondent from being interviewed.)
Respondent refused to be interviewed.
No interview obtained for a reason other than any
of the above (explain)
Owns
Rents
Don't know
Other (specify)
-------
E-1
ID
DK
E-1
5 6
1-2
-------
E-2
E-3
E-4
E-5
E-6
E-7
E-8
E-9
What is the number of years the
probable respondent has lived in the
household unit?
What is the number of people living
in the household unit?
Is the probable respondent currently
living with spouse?
What is the sex of the probable
respondent?
What is the age of the probable
respondent?
What is the employment status of
the probable respondent?
What is the occupation of the
probable respondent?
i 1 j
*—-'
2D
3D
4 D
8D
1 D
IwJ
2D
3D
"D
5D
6D
8 D
°D
i r~i
8D
1D
2D
8n
j, Q
3D
•* n
5 n
8D
in
2D
3 Q
"D
5D
8 D
•D
5 years or less
6 - 10 years
11 - 20 years
21 or more years
Don't know
1
2
3-4
5-6
7-10
11 or Bore
Don't know
No
Yes
Don't know
Hale
Female
Don't know
Under 18
18 - 29
30-44
45-64
65 +
Don't know
Head working
Head going to school
Head keeping house
Head retired
Head unemployed
Don't know
(Job title)
C
(Duties)
<
Don't know
-------
E-2
E-3
E-H
E-5
E-6
E-7
E-8
1Q
11
12
13
15
E-9
16
19
-------
E-3
E-10 What is the ethnicity of the probable 1
respondent?
2
3
»
5
8
E-ll What is the educational attainment 1
of the probable respondent?
2
3
4
8
E-12 What is the total income of the 01
probable respondent's household?
02
03
04
05
06
07
08
09
10
11
-8
E-13 From which of the following does this 01
household unit get its drinking water?
02
03
OH
05
06
07
-8
j I White (Not of Hispanic origin)
P~l Black (Not of Hispanic origin)
r~j Hispanic
I I American Indian or Alaskan Native
1 1 Asian or Pacific Islander
1 1 Don't know
j [ Grade school (1-6 years)
1 1 Junior high (7 - 9)
I 1 High school (10 - 12)
| | College
r~j Don't know
Q 0 - 2999 dollars
f~| 3000 - 5999 dollars
Q 6000 - 8999 dollars
Q 9000 - 11999 dollars
P~| 12000 - 14999 dollars
Q 15000 - 17999 dollars
£] 18000 - 20999 dollars
P] 21000 - 23999 dollars
r~\ 24000 - 26999 dollars
P] 27000 - 29999 dollars
P] 30000 + dollars
| | Don't know
1 ] Water system with 15 or more households or that
— serves more than 25 people
D wel1
PJ Spring
r~| Surface water (pond, lake, river, stream)
1 I Cistern
I I Hauled
I j Purchased, bottled
1 1 Don't know
-------
E-3
E-10
E-11
E-12
20
21
22 23
E-13
24 25
-------
E-4
EXPLANATORY NOTES I . __^
INTERVIEWER ISSTRUCTION: Vote below any detailed camente which would explain or olarify the non-interview
situation. If a comtent refers to a specific question in Section E, note the question number.
*O.S. GOTESHMENT PRINTING OFFICE ! 1978 0-720-335/60€4
-------