This survey relates to domestic water use ONLY. Domestic water means tap water supplied via plumbing fittings to your home and used for drinking, cooking, washing , laundry, sanitation and other household purposes. The survey takes approximately 7 minutes

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* 1. Please specify how many people  in the relevant age groups currently live at your residence.

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* 2. Does anyone at your residence identify as having a chronic health condition or immunocompromised such as transplant patients, cancer patient dialysis patients or other? Check the appropriate.

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* 3. Approximately how much water is  used in total at your residence for domestic purposes each day?

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* 4. Where is your domestic watersourced from? Please check the applicable boxes.
Rainwater: Collected from roofs and stored within a tank for future use.

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* 5. If yes to rainwater,please check the following  that apply:

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* 6. Surface Water: Drawn from rivers, creeks, and dams which may or mayn't be stored in a tank prior to use.

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* 7. If yes to surface water, please check the following that apply.

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* 8. Shallow groundwater: Drawn from bores, wells or springs that are 1-20 metres deep which may or may not be stored in a tank prior to use.

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* 9. If yes to shallow groundwater, please check the following that apply.

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* 10. Deep groundwater: drawn from bores, wells or springs that are greater than 20 metres deep, which may or may not be stored in a tank prior to use.

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* 11. If yes to deep groundwater, please check the following that apply.

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* 12. Carted Water: from mains or town water supply transferred by tanker and stored in a tank prior to use.

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* 13. If yes to carted water, please check the following  that apply.

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* 14. If you use a  tank to  store your domestic water, which of the following best describes your tank? Check the most apropriate.

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* 15. Which best describes the type (s) of water treatment used on your domestic water supply? Check all that apply.

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* 16. What part of your residence is supplied treated water? Check the most appropriate answer.

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* 17. Specify if domestic water used for the following activities at your residence is treated. Please check yes or no for each.

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* 18. Is private domestic water provided to a business? Check all appropriate.

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* 19. On a scale of one to ten how satisfied are you with the quality of your domestic water supply. Where one is very dissatisfied and ten is very satisfied Check the most appropriate answer.

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* 20. On a scale of one to ten how concerned are you about the safety of your domestic water supply? Where one is very concerned and ten is not concerned at all.Check the most appropriate answer.

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* 21. How would you describe the land use for the property on which your private water sources and residence are located?  Check all that apply.

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* 22. When undertaking the land use activity for the property on which your private water sources and residence are located do you use any of the following? Check all that apply.

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* 23. Do you wish to make any additional comments relating to your private domestic water supply?

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* 24. Please provide your address for analytical purposes.  This will be used in compliance with the Privacy Act.

Thank you for your participation. Please remember to return this survey.
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