| Part 1: Contact Information |
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Organization Name:
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Organization's Street Address:
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City:
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State:
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Zip Code:
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Organization Telephone:
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Fax:
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Website:
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Name & Title of
Agency Contact:
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Contact Person's
Telephone:
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Contact's
E-Mail:
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| Part 2: Questions |
1. What are the most common health related problems that your constituents/members report that you think are related to the environment? How frequently are these problems reported per month?
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2. Have your constituents/members ever inquired about any of the following conditions? (Please check all that apply)
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3. What questions do your constituents/members ask your organization about housing quality, such as repair and maintenance, apartment/building conditions, and/or negligent landlords? (ex: trash pile-up, loose stairwell railing, rodent problems)
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4. How many constituents/members, on average, complain of asthma or respiratory-related illness (e.g. bronchitis, emphysema, allergies) per month?
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5. Where do your constituents/members currently go to receive information on health and housing issues? (ex: clinics, family, newspapers, tenant associations, schools, Dept. of Health)?
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6. WE ACT will schedule Healthy Homes' trainings/workshops for interested organizations and groups. Which of the following trainings would you and/or your constituents most likely attend? (Please check all that apply).
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7. What environmental health resources would best benefit your constituents? (Please check all that apply).
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8. Tell us how likely is your participation in a citywide Housing & Health Leadership Council that is empowered to advocate for policy reforms and improved housing conditions. (Please check all that apply)
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9. Please take a moment to recommend other groups who might benefit from our Healthy Homes workshops:
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Part 3: In addition to the survey, here are some questions pertaining to common situations that occur in the home.
Your answers will help us create workshops that address environmental issues that are common to you and your family. Please respond to the questions honestly. |
1. If a constituent/member walks into his/her building and sees a large crack in the wall with paint chipping along the edges of the crack, what does s/he do?
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2. On Monday, a tenant enters her kitchen and sees two cockroaches crawling on the floor. She kills the cockroaches by stepping on them. The next day, she sees three more cockroaches crawling on her kitchen floor and along the wall, what does she do about this recurring problem?
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3. A young child is sitting in the living room watching television. Her father comes into the room and lights up a cigarette. What do you do?
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4. A tenant notices that a fuzzy, dark green mold is growing on the surface of her sink in the bathroom. The bathroom is damp with moisture and the mold often reappears, so the woman is unsure of how to permanently remove the mold from her sink. She should:
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5. We welcome any additional comments you would like to provide:
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