KNED Help Desk

File II: Questionnaire for Environmental Concerns

The Kaw Nation Environmental Department is conducting a survey of the environmental concerns of Kaw tribal members. If you are a registered member of the tribe, your participation in this survey is strongly encouraged. Your feedback can improve the quality of services offered by the KNED and can increase the likelihood of federal funding for specific projects. Please take a moment and complete this short online form. If you have any questions about this or other environmental issues please call 580/269-2552. Thank you.

Name	Physical Address	Email Address	Telephone Number
I am a registered member of the Kaw Nation. Yes	1.) Please rate the degree of environmental concern, from 1 to 5, that you have about the following items in your area using the number 1 for the highest priority.	Water Quality Wastewater Disposal Air Quality Solid Waste Disposal	Mining Oil Arial Spray Other
2.) Do you feel that any of these concerns pose an immediate threat to your family health?	Yes No	3.) What areas of Environmental Protection would you like to see our department focus on?	Please Describe
4.) What areas of Environmental Education would you like for our Environmental Department to provide for yourself and/or your children?	Please Describe	5.) From which of the following sources does the water you use for domestic purposes come from?	Domestic Well Rural Water Supply Municipal Water Supply
6.) For those of you who are using a domestic well, please answer the following questions:	Have you had any water quality samples done? Yes No	Have any of the test results indicated concerns? Yes No	Would you like to have some testing done? Yes No
7.) How do you dispose of domestic wastewater?	Septic Tank Municipal Collection System	8.) Would you like to have more information on proper operation and maintenance of your septic tank?	Yes No
9.) Have you had your home checked for asbestos?	Yes No	10.) Would you like to have your home checked for asbestos?	Yes No
11.) Have you had your home checked for radon?	Yes No	12.) Would you like to have your home checked for radon?	Yes No
13.) Have you had your water checked for lead and copper?	Yes No	14.) Would you like to have your water checked for lead and copper?	Yes No
15.) Would you like to have your home checked for mold?	Yes No	16.) Have you or anyone in your family or neighborhood had any health problems that you think might be caused by something occurring in your home or your neighborhood?	Yes No
17.) If you have any other areas of interest or concern that are related to the environment not mentioned in this questionnaire, please specify:	Please Specify