These questionnaires are anonymous- If you would like to discuss the questionnaire further or find out results, please contact us by phone at (415) 643-1870 or by email ruthbreeth@gcrnonitororg. Please visit our hompage for all the latest information: http:/twww.gcrnonitor.org
For additional information about the air monitoring project, please visit http://www.berkeleycitizen.org/monitoring.html If you would like to volunteer your rooftop for air sampling, please contact L A Wood at bcitizen@berkeleycitizenorg. Thank you for your time and we appreciate your service for our community.
West Berkeley Community Health Survey
Hello, my name is _______________, I am a student at the University of California, Berkeley. I am currently a volunteer with the West Berkeley Community Air Monitoring Project. We are a community based organization that works together with members of our community to make our neighborhood healthy and safe. We are concerned about the many environmental problems that affect our community’s health regarding Pacific Steel Casting emissions. We are conducting a short community health survey to get a better idea about health issues and air quality in West Berkeley. These surveys are anonymous and will remain confidential. We want to ask you a few questions about your experiences in the neighborhood. Feel free to disregard any questions you don’t feel comfortable answering.
What is your age? ______
What is their gender? ? Male ? Female
How long have you lived at the present address? ? Less than a year ? 1 to 5 year’s ? 6-15 years ? 16-30 years ? More than 30 years ? Not sure
How far from Pacific Steel Casting (at Gilman & Second St.) do you live?
? less than 5 blocks ? 5-9 blocks ? 10+ blocks
What is your sense of the overall air quality in your community?
? Clean ? Average ? Not so clean ? Unbearable
In the past six months, have you smelled anything unusual?
? Daily ? Weekly ? Monthly ? Less Often ? Not Sure
Does the noise interfere with your sleep or the sleep of anyone in your house?
? No ? Yes ? Not now, because I/we got used to the noise
If yes, how often? ? Daily ? Weekly ? Monthly
Have you been tested for metals? (hair, blood, etc) ? Yes ? No
Do you complain to the Bay Area Air Quality Management District?
?Daily ?Weekly ?Monthly ?Yearly ?Other _______
Do you have the following symptoms?
Symptoms |
How Often Symptoms Occur |
List age(s) of all affected household members |
Never |
Rarely |
Occasionally |
Frequently |
Constantly |
Asthma |
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Coughing |
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Chest pains |
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Sore Throat |
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Shortness of breath |
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Sinus infections |
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Chronic bronchitis or pneumonia |
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Headaches |
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Throat irritation |
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Skin rash/irritation |
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Nausea |
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Insomnia |
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Learning problems |
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Any additional comments: __________________________________________________________
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