Survey Number: «Survey_Number»
SECTION A: HOME INFORMATION
A1. Home Address/Location: r Aleknagik r Dillingham
(Optional)
______
A2. How many people live in your home? ______
A3. What is the size of your home?
Survey Number: «Survey_Number»
r 1,000 sq. ft. or less
r 1,001 – 1,500 sq. ft.
r 1,501 sq. ft. or more
r I Don’t Know/Not Sure
Survey Number: «Survey_Number»
A4. How old is your home?
Survey Number: «Survey_Number»
r Less than 1 Year
r 1-5 Years
r 6-10 Years
r 11-15 Years
r 15+ Years
r I Don’t Know/Not Sure
Survey Number: «Survey_Number»
A5. Has your home had an energy audit OR weatherization?
r Yes
r No
r I Don’t Know/Not Sure
SECTION B: HOME HEATING (PRIMARY & SECONDARY)
B1. What is the primary heating source for your Home?
r Heating (Stove) Oil
r Firewood
r Pellets/Briquettes
r Other (please specify) ______
r I Don’t Know/Not Sure
B2. What is the manufacture name & model number of your primary heating system?
______
B3. If your primary heating system is a wood stove, is it EPA certified?
r Yes Month ______Year ______
r No
r I Don’t Know/Not Sure
r Does Not Apply
B4. How old is your primary heating system?
Survey Number: «Survey_Number»
r Less than 1 Year
r 1-5 Years
r 6-10 Years
r 11-15 Years
r 15+ Years
r I Don’t Know/Not Sure
Survey Number: «Survey_Number»
B5. What is the secondary heating source for your Home? r Does Not Apply
r Heating (Stove) Oil
r Firewood
r Pellets/Briquettes
r Other (please specify) ______
rI Don’t Know/Not Sure
B6. What is the manufacture name & model number of your secondary heating system?
______
B7. If your secondary heating system is a wood stove, is it EPA certified?
r Yes Month ______Year ______
r No
r I Don’t Know/Not Sure
r Does Not Apply
B8. How old is your secondary heating system?
Survey Number: «Survey_Number»
r Less than 1 Year
r 1-5 Years
r 6-10 Years
r 11-15 Years
r 15+ Years
r I Don’t Know/Not Sure
Survey Number: «Survey_Number»
SECTION C: HOME HEATING WITH FIREWOOD
If you do not heat your home with firewood, please go to the NEXT section.
C1. What type of firewood have you burned in the past year?
Survey Number: «Survey_Number»
r Birch
r Spruce
r Pallets/Scrap Wood
r Other (please specify) ______
r I Don’t Know/Not Sure
Survey Number: «Survey_Number»
C2. How far have you travelled to harvest firewood in the past year?
Survey Number: «Survey_Number»
r Less than 5 Miles
r 5-10 Miles
r 11-20 Miles
r 21 Miles +
r I Buy My Wood
r I Get My Wood from Family/Friend
r I Don’t Know/Not Sure
Survey Number: «Survey_Number»
C3. How long do you dry your firewood before burning it?
Survey Number: «Survey_Number»
r Hours
r Days
r Weeks
r Months
r Years
r I Harvest only Dry Wood
r I Don’t Know/Not Sure
Survey Number: «Survey_Number»
C4. How do you store/stack your firewood?
Survey Number: «Survey_Number»
r Stacked Outside/Covered
r Wood Shed
r Stacked Outside/Uncovered
r I Don’t Know/Not Sure
Survey Number: «Survey_Number»
C5. How much have you burned in the past year?
# Cord(s) (Firewood): ______(Sled is about 1/3 Cord)
# Pounds (Pellets/Briquettes): ______
r I Don’t Know/Not Sure
C6. How familiar are you with EPA certified wood stoves?
Survey Number: «Survey_Number»
r Very Familiar
r Somewhat Familiar
r Not at All Familiar
r I Don’t Know/Not Sure
SECTION D: STEAM BATH
D1. Do you own a Steam Bath? r Yes r No (Go to Next Section)
D2. What is the heating source for your Steam?
r Oil
r Wood
r Other (please specify) ______
r I Don’t Know/Not Sure
D3. How often do you light your Steam?
Survey Number: «Survey_Number»
r Daily
r A Few Times a Week
r A Few Times a Month
r I Don’t Know/Not Sure
D4. If you heat your Steam with firewood, what type have you burned in the past year?
r Birch
r Spruce
r Other (please specify) ______
r I Don’t Know/Not Sure
r Does Not Apply
D5. If you heat your Steam with firewood, how far have you travelled to harvest wood in the past year?
Survey Number: «Survey_Number»
r Less than 5 miles
r 5-10 miles
r 11-20 miles
r 21 miles +
r I Buy My Wood
r I Don’t Know/Not Sure
r Does Not Apply
Survey Number: «Survey_Number»
D6. If you heat your Steam with firewood, how much have you burned in the past year?
# Cord(s) (Firewood): ______(Sled is about 1/3 Cord)
r I Don’t Know/Not Sure
SECTION E: SMOKE HOUSE
E1. Do you own a Smoke House? r Yes r No (Go to Next Section)
E2. What type of firewood have you burned in the past year in you Smoke House? (Please check all that apply)
r Cottonwood
r Alder
r Birch
r Driftwood
r Other (please specify) ______
r I Buy My Wood
r I Don’t Know/Not Sure
E3. How far have you travelled to harvest firewood for your Smoke House in the past year?
Survey Number: «Survey_Number»
r Less than 5 miles
r 5-10 miles
r 11-20 miles
r 21 miles +
r I Buy My Wood
r I Don’t Know/Not Sure
Survey Number: «Survey_Number»
E4. How much firewood have you burned for you Smoke House in the past year?
r I Cord
r 1/2 Cord
r 1/3 Cord (sled size)
r 1/4 Cord
r I Don’t Know/Not Sure
OTHER
SECTION F: OTHER
F1. Would you like more information on any of the following?
Survey Number: «Survey_Number»
r Home Energy Efficiency
r Home Energy Audits/Weatherization
r Wood Stove Efficiency
r Wood Stove Cleaning & Maintenance
r Wood Drying
r Burn Wise (EPA Program)
r Wood Smoke & Air Quality
r Lot Management
r Other ______
Survey Number: «Survey_Number»
F2. Do you have any questions, concerns, comments?
______
______