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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?
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Not at all concerned
Slightly concerned
Moderately concerned
Very concerned
How concerned are you about water pollution in your community?
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Not at all concerned
Slightly concerned
Moderately concerned
Very concerned
How concerned are you about air pollution in your community?
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Not at all concerned
Slightly concerned
Moderately concerned
Very concerned
How concerned are you about solid waste pollution in your community?
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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?
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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?
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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?
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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)?
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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.
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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?
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Is there any activity in your community addressed to improve that life-quality?
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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?
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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)?
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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?
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Yes
No
Letter of Consent
Submit
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