Occupational Health: Water Survey 2002

Cornell University Risk Management and Public Safety Environmental Health & Safety

The Department of Environmental Health and Safety (EH&S) is conducting a survey to understand drinking water quality at off-site facilities. This program will help us understand the types of drinking water sources and systems we have at off-site facilities, assess the quality of the drinking water at the site and assist in compliance with state and federal drinking water standards.

Please complete this short survey and Return To Suzanne Sears, EH&S, 395 Pine Tree Rd., Ithaca NY 14850 or e-mail srs7@cornell.edu by 7/26/02, so we can understand the situation at your facility.

Name of Person Filling out the form:
Email of person filling out the form: (ex: xyz21@cornell.edu)

1. At any of your facilities, is your drinking water supplied by a well?
     Yes    No

2. If your water supply is from a well, is it a drilled well or a dug well?
     Drilled    Dug    Don't Know

3. Does the water supply have five or more service connections* or serve at least 25 people or more for 60 days of the year?   Yes    No    5 or more service connections    25 people

4. If so to Question 3, are these the same people at the site every day or are they visitors or a transient population (i.e. visiting researchers)?   Same    Transient    Mix (same/transient)

5. Has the water supply ever been tested? If so, please check all that apply:
Tested?    Yes    No

Microbiological
Organic chemicals including pesticides
Inorganic chemicals

If you know, when was it last tested?
Any problems?

6a. Are you the appropriate facility contact to answer questions about drinking water at the site?
Yes

If not, who is?
Name:
E-mail:

7. Is there anything else you would like to report that would help us describe the situation at your facility?

Thank you for your time and I look forward to working with you in the future. If you have any questions please e-mail me at jrg5@cornell.edu.

*Service Connection: Means the pertinent pipes, valves and fittings that connect a distribution system
to a consumer's facility.

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