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Title of Study: Perceived Health Effects of Natural Gas Drilling in Pennsylvania
Informed Consent
Please read over the following information carefully before participating in the study
You are invited to participate in a research study about the perceived health effects of natural gas drilling in Pennsylvania. Tara Banfield of Keystone College is conducting this study. The purpose of the study is to identify public health issues from natural gas drilling in Tioga, Bradford, Wyoming, and Lackawanna counties. You must be eighteen years or older to participate.
There are no known risks if you decide to participate in this research study. There are no costs to you for participating in the study. The information collected may not benefit you directly, but the information learned in this study should provide more general benefits.
This survey is anonymous. Do not write your name on the survey. No one will be able to identify you or your answers, although if completing this survey online, your user name, IP address, or any other internet ID may connect your name with the completion of this survey. The Institutional Review Board has approved this study.
Your participation is voluntary, and by completion of survey you are agreeing to participate. You are free to decline to answer any particular questions.
If you have any questions about the study, please contact Tara Banfield at or Keystone College.

Circle or Highlight the following that apply to you

Sex: Male Female

Age: 18-30 31-40 41-50 51-60 61-70 71+

Education:

No or Some High School High School Diploma/GED Associate’s Degree

Some College/Vocational School /Technical Training Bachelor’s Degree or higher

Best description of the type of organization you work for:

Non-worker Government For Profit

HealthCare Education Non-profit (religious, arts, social)

Do you have any dependents that live in the same household? Yes No

Your permanent county residence: Lackawanna Wyoming Tioga Bradford

Do you smoke? Yes No Occasionally

Do you usually drink more than one alcoholic beverage a day? Yes No

Are you, or anyone you are related to, working for a natural gas company? Yes No Not Sure

Are you, or anyone you are related to, working for an environmental company? Yes No Not Sure

How far away is your house from the nearest active/inactive gas drilling site?

0 - 3 miles 3.1 – 5.0 miles 5.1- 7.0 miles 7.1 – 9.0 miles 9.1+ miles

Have you leased or plan to lease land to the gas companies? Yes No

Have you received Royalties? Yes No

Do you know if the gas drilling site nearest you has been issued any violations?

Yes No Not sure

How do you feel the gas drilling has affected your county?

For the better For the worse No change Not Sure

Do you believe that gas drilling near your house is harmful to you or your family?

Yes No Not sure

Have you had your water or air quality tested? Yes No

If yes, how were the results? Average Good Bad Unable to Answer

Have you spoken to your doctor about your concerns for natural gas drilling? Yes No

Have you, or any household members, experienced changes in the following health issues since gas drilling has arrived in your county? Mark an X under the column that applies

Issues: / INCREASE / SAME/NO CHANGE / DECREASE / NOT SURE
Asthma
Sneezing, Coughing, or Difficulty breathing
Itchy Eyes
Itchy Skin or Rashes
Hair Loss
High Blood Pressure
Chest Pain
Digestion problems
Ulcers
Dizziness
Difficulty Sleeping
Anxiety
Stress Related Issues
Pregnancy Loss/Issues

If you marked INCREASE for any of these health concerns, have you seen a doctor about the symptoms? Yes No

Did your doctor relate the issues to natural gas drilling? Yes No Not Sure

Please leave additional comments below.