• To complete this Application Assignment, begin collecting data regarding the location you have identified as follows:
o Complete Section 1: Healthy Homes Model Resident Questionnaire using yourself as the subject, or interview a volunteer* (neighbor, family member, or friend).
o Take pictures or make drawings of any areas of interest to include in your final report, which will be submitted in Week 5.
• *Remember—if using a volunteer, inform them that you are a student taking a class and that their participation is totally voluntary. Also, explain how the information you gather will be used.

MY Jurisdiction is CALIFORNIA

Section 1


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).


Yes No Why not: _____________________________________________ Vacant

Date: _________________ Name of Questionnaire Administrator: _____________________

Building and/or Unit Address: ____________________________________________________

City, State, Zip: _______________________________________________________________

No. of persons living in unit: _______________ No. of children: _______________

Age of children living in unit: _______________

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.

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


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.


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


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.

• 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

• Required Resources
• Video: Films Media Group. (2009). Shelter in place: Living in the shadows of the petrochemical industry. United States: Films Media Group.
Copyright 2009. Used by permission of Films Media Group.

Note: The approximate length of this media piece is 48 minutes.

Note: This program is not available for download. You must view the program in the media player provided below.

• Course Text: Essentials of Environmental Health

o Review Chapter 2, “Environmental Epidemiology”c c c < /font>
o Chapter 3, “ Environmental Toxicology”< /font>
o Chapter 4, “Environmental Policy and Regulation”& amp; lt; /font>
o PowerPoint: Chapter 3, “Environmental Toxicology”
o PowerPoint: Chapter 4, “Environmental Policy and Regulation”
• Article: Puckett, J. (2003). Recycling: No excuse for global environmental injustice. Seattle, WA: Basel Action Network.
Copyright 2003 by Basel Action Network. Reprinted by permission of Basel Action Network.
• Web Article: Elgin, B. & Grow, B. (2008, October 15). E-Waste: The dirty secret of recycling electronics. Bloomberg Businessweek, 8(43). Retrieved from
Web Resources
• Essentials of Environmental Health Flashcards

o Chapter 3, “Environmental Toxicology”
o Chapter 4, “Environmental Policy and Regulation”
• Agency for Toxic Substances and Disease Registry. (2011). Agency for toxic substances and disease registry. Retrieved from
• Centers for Disease Control and Prevention. (2011). National institute for occupational safety and health (NIOSH). Retrieved from
• U.S. Food and Drug Administration. (2011). U.S. food and drug administration. Retrieved from
• U.S. Environmental Protection Agency. (2011). U.S. environmental protection agency. Retrieved from
• U.S. Environmental Protection Agency. (2011). eCycling. Retrieved from
Optional Resources
• Cabellos, E., & Boyd, S. (Producers). (2002). Choropampa: The price of gold [Motion picture]. United States: Icarus Films.
• Cano, L. (Producer), Hirsch, B. (Producer), & Nichols, M. (Director). (1983). Silkwood [Motion picture]. United States: Twentieth Century Fox Film Corporation.
• Devito, D. (Producer), Shamberg, M. (Producer), Sher, S. (Producer), & Soderbergh, S. (Director). (2000). Erin Brockovich. [Motion picture]. United States: Universal Pictures.

What We Offer:
• On-time delivery guarantee
• PhD-level professionals
• Automatic plagiarism check
• 100% money-back guarantee
• 100% Privacy and Confidentiality
• High Quality custom-written papers