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Natural Gas Exploration and Production Health and Community Impacts Survey

Introduction and Confidentiality

Damascus Citizens for Sustainability

Natural Gas Exploration & Production (NGE&P) Health and Community Impacts Survey
© 2013 Damascus Citizens for Sustainability - all rights reserved

 

Welcome

Thank you for taking the time to participate in our Survey. As you complete this Survey, you will be asked a series of questions designed to capture information from your area related to Natural Gas Exploration and Production, (referred to as "NGE&P activities"). Because your privacy is important to us, the first item is your confidentiality agreement. Please check the two boxes to complete the Survey online. You will be able to change, revise or add to your Survey responses at any time up to submission, and ATSDR will only receive your Survey responses when you submit them at the end of the Survey.

Would you like to submit your Survey with others as a group? (FAQ #14) That’s the best way to document the big picture of the impacts of NGE&P in your community!

If you want to submit with others in your community, choose a Group Name/Identifier before starting. To create a Multi-Household Group Name/Identifier, combine: An approximate location of your Multi-Household Group + Your Multi-Household Group's primary ZIP Code + the date your Multi-Household Group was formed. Example: If your Multi-Household Group is located in Fort Worth Texas, has a zip code of 76108 and was formed on May 3, 2013, your Multi-Household ID (MHID) will be: FortWorth761085313). (If you’re not submitting the Survey as part of a group, please proceed!)

  • If you need help with your Group Identifier or for any other questions, you can contact us by email at Survey@DamascusCitizensATSDR.org, by phone at (845) 252-6677 or write to us at DCS, P.O. Box 147, Milanville, PA 18443. We’re happy to help!
You can complete this survey in multiple sessions - stop, leave the survey at any time and come back to where you left off - all you need is an email link, which you can get at the top of any Survey page. 

*Note - When navigating the Survey, please be sure to use the Survey’s “Next” and “Back” buttons - not the ones on your computer’s browser.

Copy of

Damascus Citizens for Sustainability

Natural Gas Exploration & Production (NGE&P) Health and Community Impacts Survey
© 2013 Damascus Citizens for Sustainability - all rights reserved

 

Welcome

Thank you for taking the time to participate in our Survey. As you complete this Survey, you will be asked a series of questions designed to capture information from your area related to Natural Gas Exploration and Production, (referred to as "NGE&P activities"). Because your privacy is important to us, the first item is your confidentiality agreement. Please check the two boxes to complete the Survey online. You will be able to change, revise or add to your Survey responses at any time up to submission, and ATSDR will only receive your Survey responses when you submit them at the end of the Survey.

Would you like to submit your Survey with others as a group? (FAQ #14) That’s the best way to document the big picture of the impacts of NGE&P in your community!

If you want to submit with others in your community, choose a Group Name/Identifier before starting. To create a Multi-Household Group Name/Identifier, combine: An approximate location of your Multi-Household Group + Your Multi-Household Group's primary ZIP Code + the date your Multi-Household Group was formed. Example: If your Multi-Household Group is located in Fort Worth Texas, has a zip code of 76108 and was formed on May 3, 2013, your Multi-Household ID (MHID) will be: FortWorth761085313). (If you’re not submitting the Survey as part of a group, please proceed!)

  • If you need help with your Group Identifier or for any other questions, you can contact us by email at Survey@DamascusCitizensATSDR.org, by phone at (845) 252-6677 or write to us at DCS, P.O. Box 147, Milanville, PA 18443. We’re happy to help!
You can complete this survey in multiple sessions - stop, leave the survey at any time and come back to where you left off - all you need is an email link, which you can get at the top of any Survey page. 

*Note - When navigating the Survey, please be sure to use the Survey’s “Next” and “Back” buttons - not the ones on your computer’s browser.

Confidentiality Agreement (required) *This question is required.Check both boxes below in order to continue the survey on-line. If you don’t want to take the Survey on-line, click here to download the pdf for manual completion. 
(The Agency for Toxic Substances and Disease Registry is referred to throughout this Survey as ATSDR.)

Damascus Citizens for Sustainability respects your privacy. We will not share your personal information or survey answers without your express permission. 
Cautionary note:
  • If you have signed a Non-Disclosure Agreement (NDA) related to NGE&P, consult an attorney before taking this survey. If you've signed an NDA, that contract may state that you are prohibited from even the acknowledgment of its existence, so be careful!  No matter how firmly you believe in the urgent need for health assessments and national databases, do not put yourself at legal risk.
  • If you are involved in legal action related to NGE&P, consult with your attorney before taking this survey. Your attorney is invited to contact DCS to learn more about the Survey. 


Confidentiality Agreement

Damascus Citizens for Sustainability (DCS) will not share your personal information or survey answers with anyone other than ATSDR without your express permission.

The Agency for Toxic Substances and Disease Registry (ATSDR) is a federal agency charged with the protection of human health. In the course of its work, ATSDR may forward your survey answers and personal information to the Environmental Protection Agency, your state environmental and health departments and the US Coast Guard's National Response Center.

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