Health Survey Printouts
Please make sure to note these directions when filling out the survey
Page 1-Residential Information
- Make sure to list other residences in Val Verde they have lived in and for how many years
- Make sure to list EVERYONE who lives in the house, especially children and how many years they have been living there.
Page 2-Medical Information
- Please make sure you report only symptoms occurring AFTER the start date of your residency in Val Verde.
- For the symptoms, make sure to circle and include initials of those experiencing the symptoms. For example if both the you and kids are experiencing irritation of the eyes you would circle it then add all of their initials next to the circle (TI IS VERY IMPORTANT FOR US TO GET SYMPTOMS FROM EVERYONE AT THE RESIDENCE)
Page 3- Medical Information Continued
- If you didn’t seek medical attention for symptoms, please ask them to share why they didn’t. (money, didn’t consider it, etc)
Page 4 – Odor Assessment
- If you did not report landfill smells make sure they tell us why they didn’t report them. (didn’t realize it was the landfill, didn’t know they could report it, etc)
- Make sure to SIGN AND DATE IT.