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HEALTHY HOMES MODEL RESIDENT QUESTIONNAIRE Information from questionnaire responses such as these can provide important clues that point to housing deficiencies. The Healthy Homes Model Resident Questionnaire is a tool that can be adapted by local jurisdictions to meet their specific needs. Be sure to follow local jurisdiction regulations for the collection and safeguarding of personal data
• To complete this Application Assignment, begin collecting data regarding the location you have identified as follows:
o Complete Section 1: Healthy Homes Model Resident Questionnaire using yourself as the subject, or interview a volunteer* (neighbor, family member, or friend).
o Take pictures or make drawings of any areas of interest to include in your final report, which will be submitted in Week 5.
• *Remember—if using a volunteer, inform them that you are a student taking a class and that their participation is totally voluntary. Also, explain how the information you gather will be used.
MY Jurisdiction is CALIFORNIA
I WOULD LIKE A VOLUNTEER TO BE UED
HEALTHY HOMES MODEL RESIDENT QUESTIONNAIRE
Information from questionnaire responses such as these can provide important clues that point to housing deficiencies. The Healthy Homes Model Resident Questionnaire is a tool that can be adapted by local jurisdictions to meet their specific needs. Be sure to follow local jurisdiction regulations for the collection and safeguarding of personal data.
For example, jurisdictions may want to add questions about
• Whether the respondent owns or rents the building/unit
• The name and contact information of the building/unit owner (rental units)
• Whether the building/unit is privately owned or owned by a public housing authority
• Whether the government pays some of the cost of the building/unit
• The name of the person who is responding to the questionnaire.
This questionnaire was adapted from the pediatric environmental home assessment (PEHA) created by the National Center for Healthy Housing. PEHA forms and a PEHA Nursing Care Plan can be downloaded from http://www.healthyhomestraining.org/Nurse/PEHA.htm.
The questionnaire should be used to collect information that cannot be determined without asking questions of a resident. Information that can be determined visually should be collected on the Visual Assessment Data Collection Form (Section 2).
WAS QUESTIONNAIRE ADMINISTERED?
Yes No Why not: _____________________________________________ Vacant
Date: _________________ Name of Questionnaire Administrator: _____________________
Building and/or Unit Address: ____________________________________________________
City, State, Zip: _______________________________________________________________
No. of persons living in unit: _______________ No. of children: _______________
Age of children living in unit: _______________
Unit status Occupied Vacant
NOTE: For each questionnaire item, bolded responses indicate areas of greater concern.
Responses are ordered from most potential hazard to least potential hazard.
GENERAL HOUSING CHARACTERISTICS
Type of ownership Own house Rental house
Age of home Pre-1950 1950–1978 Do not know Post-1978
Floors lived in (check all that apply) Basement 1st 2nd 3rd or higher
Heating filters changed in past 3 months No Do not know Yes Not applicable
Heating filters (type) Do not know HEPA filter Not applicable
Heating control Hard to control heat Easy to control heat
Cooling method used No air conditioning Windows Fans Central/window air conditioner
Ventilation (check all that apply) Opens window at least once a week Kitchen and bathroom fans Whole-house ventilation
House/unit built with radon mitigation venting No Do not know Yes
Chimney inspected or cleaned in past year No Do not know Yes
Heating system; water heater; and other gas, oil, or coal-burning appliances serviced by a qualified tech-nician every year No Do not know Yes
House/unit garbage collection Once every 2 weeks Once every week Twice every week Other:
House/unit water source (city water) No Do not know Yes
House/unit on city sewer No Do not know Yes
House/unit water source (individual well)1 Yes Do not know No
Well tested at least once per year for coliform bacteria, nitrates, etc. No Do not know Yes Not applicable
Well test results Do not know Known (provide): Not applicable
Septic tank pumped No Do not know Date: Not applicable
Well and septic system: location Do not know Known (where?): Not applicable
Well and septic system: distance between systems Do not know Known (how much?): Not applicable
Mold and moisture Visible water/mold damage Musty odor evident Uses dehumidifier No damage or odor
Any water problems? Inside damp-ness during heavy rains
Pets: presence Dog (#________) Cat (#________) Other: ________ No pets
Pets: management Full access in home Not allowed in bedroom Kept strictly outdoors Sleeping location:
Pests: cockroaches Family shows evidence Family reports Present in kitchen bedroom
Pests: mice Family shows evidence Family reports Present in kitchen bedroom
Pests: rats Family shows evidence Family reports Present in kitchen bedroom
Pests: bedbugs Family shows evidence Family reports Present in bedroom
Pests: use of sprays, “bombs,” or traps Once a week Once a month Once a year None
Lead paint hazards2 Loose, peeling, or chipping, paint, bare soil Not tested/Don’t know Tested, failed, and mitigated Tested and passed
Asbestos: flooring that might contain asbestos3 Damaged material Not tested/Don’t know Tested, failed, and mitigated Tested—None present
Asbestos: recently disturbed (e.g., sanding, chip¬ping) flooring that might contain asbestos3 Yes Don’t know
Radon Failed test but not mitigated Not tested/Don’t know Tested, failed, and mitigated Tested and passed
Tobacco smoke exposure4 Smoking allowed indoors Caregiver smokes Smoking only allowed outdoors No smoking allowed
Other irritants Potpourri, incense, candles Air fresheners Other strong odors (list): None
Air freshener use (how often) Continuously Once a week Once a month Never
Type of cleaning Sweep or dry mop Vacuum (non-HEPA) HEPA vacuum Damp mop and damp dusting
Vacuum (how often) Once a month or less Once a week Once a day No carpet
Damp mop (how often) kitchen, bath, other hard floors Never Once a day Once a week Once a month or less
Air purifier use Yes No Don’t know
Humidifier or dehumidifier use Reservoir not cleaned once a week Reservoir cleaned once a week
2This may be an opportunity for local jurisdictions to check for Section 1018 [lead paint disclosure] compliance.
39×9 older floor tile, 12×12 floor tile, sheet linoleum, mastic [glue used under floor tile or linoleum].
4Local jurisdictions may want to add details about where smoking is allowed (e.g., bedroom, playroom) and how many smokers live in the house/unit.
Poison control and other emergency response numbers Not posted by any phone Not posted by every phone Posted by every phone No land-line phone
All drugs and medicines stored in childproof cabinets out of reach of children No Yes
Family fire escape plan None Developed and have copy available
Safe place to meet outside in case of fire No Yes
Home fire drill practiced in last 6 months No Yes
Tested smoke alarms in past 6 months No Yes
Portable space heaters always turned off when adults leave the room or go to sleep No Yes
VOLUNTARY HEALTH ASSESSMENT DATA
Have you or anyone in the home had any of these conditions in the last 12 months or since you moved into this house/unit? Do any of these symptoms worsen when you enter the house/unit or while you are there? Do they improve after leaving? If yes, please describe.
• Doctor-diagnosed asthma
• Asthma symptoms (cough, wheezing, shortness of breath, chest tightness, and phlegm without a cold or respiratory infection)
• Chronic bronchitis
• Ear infections (three or more)
• Eye irritation
• Frequent headaches or migraines
• Hay fever
• Respiratory disease
• Sinus problems
• Skin infection/rash
• Required Resources
• Video: Films Media Group. (2009). Shelter in place: Living in the shadows of the petrochemical industry. United States: Films Media Group.
Copyright 2009. Used by permission of Films Media Group.
Note: The approximate length of this media piece is 48 minutes.
Note: This program is not available for download. You must view the program in the media player provided below.
• Course Text: Essentials of Environmental Health
o Review Chapter 2, “Environmental Epidemiology”c c c < /font>
o Chapter 3, “ Environmental Toxicology”< /font>
o Chapter 4, “Environmental Policy and Regulation”& amp; lt; /font>
o PowerPoint: Chapter 3, “Environmental Toxicology”
o PowerPoint: Chapter 4, “Environmental Policy and Regulation”
• Article: Puckett, J. (2003). Recycling: No excuse for global environmental injustice. Seattle, WA: Basel Action Network.
Copyright 2003 by Basel Action Network. Reprinted by permission of Basel Action Network.
• Web Article: Elgin, B. & Grow, B. (2008, October 15). E-Waste: The dirty secret of recycling electronics. Bloomberg Businessweek, 8(43). Retrieved from
• Essentials of Environmental Health Flashcards
o Chapter 3, “Environmental Toxicology”
o Chapter 4, “Environmental Policy and Regulation”
• Agency for Toxic Substances and Disease Registry. (2011). Agency for toxic substances and disease registry. Retrieved from
• Centers for Disease Control and Prevention. (2011). National institute for occupational safety and health (NIOSH). Retrieved from
• U.S. Food and Drug Administration. (2011). U.S. food and drug administration. Retrieved from
• U.S. Environmental Protection Agency. (2011). U.S. environmental protection agency. Retrieved from
• U.S. Environmental Protection Agency. (2011). eCycling. Retrieved from
• Cabellos, E., & Boyd, S. (Producers). (2002). Choropampa: The price of gold [Motion picture]. United States: Icarus Films.
• Cano, L. (Producer), Hirsch, B. (Producer), & Nichols, M. (Director). (1983). Silkwood [Motion picture]. United States: Twentieth Century Fox Film Corporation.
• Devito, D. (Producer), Shamberg, M. (Producer), Sher, S. (Producer), & Soderbergh, S. (Director). (2000). Erin Brockovich. [Motion picture]. United States: Universal Pictures.
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