Have you had a boil water advisory in the last 12 Months? *

Yes

No

Do you drink tap, bottled, or filtered water? *

Tap

Bottled

Filtered

Are you living in a current address for more than a year? *

Yes

No

Have you ever noticed a chlorine taste or smell in your tap water? *

Yes

No

Are you renting or owner of the house? *

Yes

No

Have you had your water tested in the last 30 days? *

Yes

No

Is clean drinking water a low, medium or high priority for you? *

Low

Medium

High

Are you in the age group of 50 to 60? Or below? 60 to 70? 80 and over? *

Below 50

50 to 60

60 to 70

70 to 80

80 and over

When you do shopping, do you usually use credit card?

Yes

No