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QualityofWaterandAnalysis:Localcommunity
Date:..

1.Name:
2.Address:
3.Block:.... 4.Village:
5.SourceofWater:(Well)(River)(Pond)(Handpump)(Supply)(other)
6.Waterrelatedissue:(Yes)(No)
7.Ifyesthanwhat:
8.ColourofWater:(Black)(Yellow)(Normal)(Others)
9.OdourinWater:(Yes)(No)
10.Tasteofwater:(Normal)(Bitter)(Sweet)(Other)
11.Waterstoragein:(Tank)(Earthenpot)(Bottle)(Bucket)(Other)
12.Colourchangeafterstorage:(Yes)(No)
13.Anytreatmentbeforeuseofwater:(Yes)(No),
14.Ifyeswhat(R.O.)(U.V.)
15.Doyouknowaboutwaterpollution:(Yes)(No)
16.Doyouknowabouttheproblemsassociatedwithcontaminatedwater:(Yes)(NO)
17.Doyouknowthatfollowingdiseasecanoccurduetowaterpollution:(Yes)(No)
Skinpollution....,Jaundice.. .,Toothproblems... ...Boneproblems...
Stomachailments... andothers
18.Anyindustrynearby:..
19.Whetherindustrialeffluenttreatedornot:
20.Anyriverinthevicinity:
21.Whethergroundandsurfacewaterisbeingpolluted:(Yes)(No)(Don'tKnow)
22.DoyouknowaboutCopperorChromium:(Yes)(No)
23.Awarenessprogramsinvillage:(Frequently)(Hardly)(Never)
24.Anybenefitfromthese:
25.Anysuggestion:

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