Nightingale

Section 1

HEALTHY HOMES MODEL RESIDENT QUESTIONNAIRE

Information from questionnaire responses such as these can provide important clues that point to housing deficiencies. The Healthy Homes Model Resident Questionnaire is a tool that can be adapted by local jurisdictions to meet their specific needs. Be sure to follow local jurisdiction regulations for the collection and safeguarding of personal data.

For example, jurisdictions may want to add questions about

• Whether the respondent owns or rents the building/unit

• The name and contact information of the building/unit owner (rental units)

• Whether the building/unit is privately owned or owned by a public housing authority

• Whether the government pays some of the cost of the building/unit

• The name of the person who is responding to the questionnaire.

This questionnaire was adapted from the pediatric environmental home assessment (PEHA) created by the National Center for Healthy Housing. PEHA forms and a PEHA Nursing Care Plan can be downloaded from http://www.healthyhomestraining.org/Nurse/PEHA.htm.

The questionnaire should be used to collect information that cannot be determined without asking questions of a resident. Information that can be determined visually should be collected on the Visual Assessment Data Collection Form (Section 2).

WAS QUESTIONNAIRE ADMINISTERED?

Yes No Why not: _____________________________________________ Vacant

Date: ___09/08/2017____ Name of Questionnaire Administrator: ___ ____

Building and/or Unit Address: ___2000 Ulster Gardens Court___________

City, State, Zip: _____Ulster, NY 12401__________________________________

No. of persons living in unit: _______2______ No. of children: _______0_______

Age of children living in unit: ______0________

Unit status Occupied Vacant

NOTE: For each questionnaire item, bolded responses indicate areas of greater concern.

Responses are ordered from most potential hazard to least potential hazard.

GENERAL HOUSING CHARACTERISTICS

Type of ownership	Own house	Rental house
Age of home	Pre-1950	1950–1978	Do not know	Post-1978
Floors lived in (check all that apply)	Basement	1st	2nd	3rd or higher
Heating filters changed in past 3 months	No	Do not know	Yes	Not applicable
Heating filters (type)	Do not know	HEPA filter	Not applicable
Heating control	Hard to control heat	Easy to control heat
Cooling method used	No air conditioning	Windows	Fans	Central/window air conditioner
Ventilation (check all that apply)	Opens window at least once a week	Kitchen and bathroom fans	Whole-house ventilation
House/unit built with radon mitigation venting	No	Do not know	Yes
Chimney inspected or cleaned in past year	No	Do not know	Yes
Heating system; water heater; and other gas, oil, or coal-burning appliances serviced by a qualified tech​nician every year	No	Do not know	Yes
House/unit garbage collection	Once every 2 weeks	Once every week	Twice every week	Other:
House/unit water source (city water)	No	Do not know	Yes
House/unit on city sewer	No	Do not know	Yes
House/unit water source (individual well)1	Yes	Do not know	No
Well tested at least once per year for coliform bacteria, nitrates, etc.	No	Do not know	Yes	Not applicable
Well test results	Do not know	Known (provide):		Not applicable
Septic tank pumped	No	Do not know	Date:	Not applicable
Well and septic system: location	Do not know	Known (where?):	Not applicable
Well and septic system: distance between systems	Do not know	Known (how much?):	Not applicable

INDOOR POLLUTANTS

Mold and moisture	Visible water/mold damage	Musty odor evident	Uses dehumidifier	No damage or odor
Any water problems?	Inside damp​ness during heavy rains	 No complaints
Pets: presence	Dog (#________)	Cat (#________)	Other: ________	No pets
Pets: management	Full access in home	Not allowed in bedroom	Kept strictly outdoors	Sleeping location:
Pests: cockroaches	Family shows evidence	Family reports	Present in kitchen bedroom other	None
Pests: mice	Family shows evidence	Family reports	Present in kitchen bedroom other	None
Pests: rats	Family shows evidence	Family reports	Present in kitchen bedroom other	None
Pests: bedbugs	Family shows evidence	Family reports	Present in bedroom other	None
Pests: use of sprays, “bombs,” or traps	Once a week	Once a month	Once a year	None
Lead paint hazards2	Loose, peeling, or chipping, paint, bare soil	Not tested/Don’t know	Tested, failed, and mitigated	Tested and passed
Asbestos: flooring that might contain asbestos3	Damaged material	Not tested/Don’t know	Tested, failed, and mitigated	Tested—None present
Asbestos: recently disturbed (e.g., sanding, chip​ping) flooring that might contain asbestos3	Yes	Don’t know 	No
Radon	Failed test but not mitigated	Not tested/Don’t know	Tested, failed, and mitigated	Tested and passed
Tobacco smoke exposure4	Smoking allowed indoors	Caregiver smokes	Smoking only allowed outdoors	No smoking allowed
Other irritants	Potpourri, incense, candles	Air fresheners	Other strong odors (list):	None
Air freshener use (how often)	Continuously	Once a week	Once a month	Never
Type of cleaning	Sweep or dry mop	Vacuum (non-HEPA)	HEPA vacuum	Damp mop and damp dusting
Vacuum (how often)	Once a month or less	Once a week	Once a day	No carpet
Damp mop (how often) kitchen, bath, other hard floors	Never	Once a day	Once a week	Once a month or less
Air purifier use	Yes	No	Don't know
Humidifier or dehumidifier use	Reservoir not cleaned once a week	Reservoir cleaned once a week

2This may be an opportunity for local jurisdictions to check for Section 1018 [lead paint disclosure] compliance.

39×9 older floor tile, 12×12 floor tile, sheet linoleum, mastic [glue used under floor tile or linoleum].

4Local jurisdictions may want to add details about where smoking is allowed (e.g., bedroom, playroom) and how many smokers live in the house/unit.

HOME SAFETY

Poison control and other emergency response numbers	Not posted by any phone	Not posted by every phone	Posted by every phone	No land-line phone
All drugs and medicines stored in childproof cabinets out of reach of children	No	Yes
Family fire escape plan	None	Developed and have copy available
Safe place to meet outside in case of fire	No	Yes
Home fire drill practiced in last 6 months	No	Yes
Tested smoke alarms in past 6 months	No	Yes
Portable space heaters always turned off when adults leave the room or go to sleep	No	Yes

VOLUNTARY HEALTH ASSESSMENT DATA

Have you or anyone in the home had any of these conditions in the last 12 months or since you moved into this house/unit? Do any of these symptoms worsen when you enter the house/unit or while you are there? Do they improve after leaving? If yes, please describe.

None

· Allergies

· Doctor-diagnosed asthma

· Asthma symptoms (cough, wheezing, shortness of breath, chest tightness, and phlegm without a cold or respiratory infection)

· Chronic bronchitis

· Ear infections (three or more)

· Eye irritation

· Frequent headaches or migraines

· Hay fever

· Respiratory disease

· Sinus problems

· Skin infection/rash

INJURIES

During the past 3 months, did you/did you or anyone in your family have an injury where any part of the body was hurt (including burns, electric shock, or falls)?5 No

Did you talk to or see a medical professional about any of these injuries? N/A

Please describe the circumstances or events leading to the injury, and any objects, substances, or other people involved. Include what the person was doing at the time. N/A

POISONINGS

Have you or anyone in your family been poisoned in the house/unit by swallowing or breathing in a harmful substance such as bleach, carbon monoxide, or too many pills or prescription medications? Do not include food poisoning, sun poisoning, or poison ivy. NO

How many different poisonings occurred? N/A

Please describe the circumstances or events leading to the poisoning/s, and any objects, substances, or other people involved. Include what the person was doing at the time.

Did you talk to or see a medical professional about any poisonings? N/A

Have any children <6 years of age in the house/unit been tested for lead poisoning? N/A

If yes, what were the test results?

Is the gas stove or oven ever used to heat the home? NO

Do you use an unvented space heater or fireplace? How often? What type of fuel do these items use? NO

5Jurisdictions may wish to consider that some of these responses could be a result of behavior issues rather than structural issues.

OTHER ISSUES

What is the occupation of adults in the household? Elementary School Teacher

If residents are responsible for maintaining the swimming pool/hot tub, do you have the required water testing equipment? Are pool chemicals stored safely? N/A

If you have firearms in your house/unit and young children live in or visit the house/unit, do the firearms have trigger locks or are they locked away and inaccessible to children? YES

Are bathroom and kitchen exhaust fans used often? YES