10-Question Survey for Home *A* Syst
Thank you for participating in the Home Assessment System (Home *A* Syst) program. This program is designed to help you identify and reduce the risk of environmental problems in and around your home. It is also very important for our office to be aware of the effect the program has, and how we can improve it. In order to do this, we ask that you print and then fill out this short l0-question survey after you have undergone the program and decided whether or not you will make (or have made) any changes recommended in the materials.
1. Which State and county do you live in? (state)_______(county)________
2. How was the program delivered to you?(please circle one letter)
a. Attended a group workshop sponsered by (please specify)__________
b. One-on-one assistance from an Extension, NRCS (SCS), or other government
person
c. One-on-one assistance from a volunteer service person (such as an AmeriCorp,
4-h, Master Gardener, or other volunteer service organization)
d. Assisted by a private consultant
e. Completed vthe program with no assistance
f. Other method of delivery (please specify)____________
3. Did you complete an assessment of your home?(please circle one letter)
a. Yes, I completed the checklist and most of the risk-questions in Chapters 1-11 that apply to me (risk-questions ask you to state a low, medium or high risk)
b. Yes, I completed the checklist section only (and not the risk-questions in Chapters 1-11).
c. No, I did not read or complete any of the materials
any of the factsheet materials.
4. What is the source of your drinking water? (please circle one letter)
| a. Private water well b. Community or municipal water supply |
c. Bottled water d. Other(please specify)_______ |
5. In which group of worksheet questions did you identify a "high risk" as it relates to your property? (please circle all those that apply)
| a. Site assessment b. Storm-water management c. Drinking water well manaagement d. Petroleum product Storage e. Household waste water (septic systems and other treatment methods) f. Managing hazardous household products |
g. g. Lead in and around the home h. Yard and garden care i. Liquid fuels (gas, oil, diesel, etc.) j. Indoor air quality k. Heating and cooling systems (energy) l. Household trash (waste prevention,etc.) |
6. Do you have any children (under age 18) living in the household?(please
circle one)
Yes
No
7. About what size lot is your house on (include all property you own that connects to the homesite)?
Please state in either footage or acres.
________feet. by ________feet
or__________acres
8. Please indicate below any recent changes you have made (or plan to make) in your home management practices or to your homesite to reduce the risk of environmental problems that are mainly a result of information you learned from undergoing the Home *A* Syst program. This question is very important to us, so please answer it as thoroughly as possible.
| Brief Description of Change | Out-of-pocket cost to you |
Time spent on change(hrs) |
Date of change |
Change is planned |
| #1) |
. | . | . | . |
| #2) |
. | . | . | . |
| #3) |
. | . | . | . |
| #4) |
. | . | . | . |
| #5) |
. | . | . | . |
9. Do you think the Home *A* Syst program was worth doing and would
you recommend it to your neighbors?(please circle one)
Yes
No
Undecided
10. How could we make the Home *A* Syst program better or more useful
for you or your neighbors?(please write in the space provided)
Thank you for your time and effort in comleting this evaluation. Please mail the completed survey to:
Deanna Osmond
NCSU
BOX 7619 Raleigh, NC 27695-7619