Would you want to know if contaminants are in your water? *

Yes

No

How would you rate your confidence in safety and quality of your tap water? *

I trust my tap water

I do not trust my tap water

Are you aware of the effects that water has on your family and home? *

Yes

No

A little bit

Do you have a plan in place for dealing with water emergencies such as leaks/floods? *

Yes

No

Do you know how to turn off your water main in case of leaks/floods? *

Yes

No

What do you use for drinking/cooking water? *

Tap water

Brita filter

Fridge filter

Bottled water

Alkaline water

Filtration system

Other

About how much do you spend on drinking water every month? *

$

Have you noticed any of the following effects from your tap water? (check all that apply)

Dry skin

Brittle hair

Foul odors

Unusual color

Corrosion

Scale or water spots

Stiff or faded clothes

Low water pressure

Water heater issues

None

Full Name *

Address *

City *

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