Sample Residential Burning Questionnaire

IMPORTANT INSTRUCTIONS. PLEASE READ. Complete only that information which applies to your household. If you do not know the information to a question, leave it unanswered and then mark through the question with your pencil or pen so that we know this information was not known.

The purpose of this questionnaire is to do an Emissions Inventory of wood burning stoves and other household burning which will lead to a better understanding of the air quality on Tribal lands.

Household street address:______

Number of persons at residence:______

  1. What is the age of your heating unit?
  2. Which fuel does your household use as the primary source of heat?

Natural Gas

Electricity

Propane

Wood

Fuel Oil

If anything other than wood is selected you may stop answering questions here.

  1. Does your household use a:

wood stove

fireplace

pellet stove (skip to question 9)

or neither? (please specify wood burning appliance)

  1. What type of wood stove or fireplace do you have:

standard fireplace

fireplace insert

conventional wood stove

If unsure of type of wood stove, was it purchased:

before July 1990

between July 1990 and July 1992

after July 1992

non-catalytic wood stove (has baffles or secondary burning chamber)

catalytic wood stove

  1. Is the wood you burn DRY or WET (Seasoned or Green)?
  2. What type of wood do you burn (example: madrone, tan oak, fir)?

If you burn a mix of types, please give relative percentage of each type burned.

  1. Estimate the amount of wood in cords (4’x4’x8’ stack) that you usually burn during a calendar year (round to the nearest half cord).
  2. If you use a pellet stove, is it:

a certified stove

an exempt stove

Please estimate the number of bags (specify size of bag; example: 40 lb.) of pellets you usually burn during the calendar year.

No. bags______, _____ Lb. bag.

  1. How many hours do you use your wood burning heat on a day you would burn?

Winter season / Rest of year
Avg. No. hrs______per day / Avg. No. hrs______per day
  1. What time(s) of day do you burn the most?

Winter season / Rest of year
5:00 am to 10:00 am /  / 5:00 am to 10:00 am
10:00 am to 1:00 pm /  / 10:00 am to 1:00 pm
1:00 pm to 5:00 pm /  / 1:00 pm to 5:00 pm
5:00 pm to 10:00 pm /  / 5:00 pm to 10:00 pm
10:00 pm to 5:00 am /  / 10:00 pm to 5:00 am
  1. How many and what months of the year do you use wood heat?

-Winter: No. months______and from______to ______

-Rest of year: No. months______and from______to ______

  1. What type of home do you live in?

single story

multi-story

and what type of construction?

wood

brick

trailer

manufactured home

mixed construction (manufactured home with wood addition, wood & brick, etc.)

  1. Are you planning on remodeling or upgrading your heating system?

If yes, please indicate what type of system you are planning to install and the approximate time frame when this may occur.

  1. Do you ever have campfires or other outside wood fires at you residence?

If yes, please indicate how often and length of burn.

  1. Do you burn papers and/or cardboard in a burn barrel at your residence?

If yes, please indicate how often and length of burn.

  1. Do you burn leaves, branches or other yard waste at your residence?

If yes, please indicate how often and length of burn.

  1. Please list any other burning that occurs at your residence, being as specific as possible about the type of material, how often, and how long burning occurs.

Thank you for your cooperation and time. If you have any questions about this questionnaire or other environmental topics/issues, feel free to contact the Environmental Director at the Tribal Office.