Environmental Health Assessment—Healthy Homes Resident Interview.Information from questionnaire responses such as these can provide important clues that point to housing deficiencies.
Environmental Health Assessment—Healthy Homes Resident Interview.Information from questionnaire responses such as these can provide important clues that point to housing deficiencies.
Environmental Health AssessmentHealthy Homes Resident Interview
¢ To complete this Application Assignment, begin collecting data regarding the location you have identified as follows:
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o Complete Section 1: Healthy Homes Model Resident Questionnaire using yourself as the subject, or interview a volunteer* (neighbor, family member, or friend).
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o Take pictures or make drawings of any areas of interest to include in your final report, which will be submitted in Week 5.
¢ *Rememberif 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.
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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.
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 ?19501978 ?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) ??s 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
INDOOR POLLUTANTS
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