Survey Tool

For all participants over 75 years of age, the following will be asked:

Do you understand that your participation is Yes

completely voluntary? No
Do you have any question before starting to fill Yes, please specify:
in the survey? No

Part A: Identity/Concern/Behavior Survey

Environmental Identity

Using a scale of 1 (strongly disagree) to 5 (strongly agree), please rate the extent to which you agree
or disagree with the following statements:

Strongly Strongly
Disagree Neutral Agree
Disagree Agree
I spend a lot of time in natural settings
1 2 3 4 5
(woods, mountains, desert, lakes, ocean)
Engaging in environmental behaviors is
1 2 3 4 5
important to me
I think of myself as a part of nature, not
1 2 3 4 5
separate from it
If I had enough time or money, I would
certainly devote some of it to working for 1 2 3 4 5
environmental causes
When I am upset or stressed, I can feel better
by spending some time outdoors 1 2 3 4 5
“experiencing and connecting with nature”
Living near wildlife is important to me; I
1 2 3 4 5
would not want to live in a city all the time
I have a lot in common with
1 2 3 4 5
environmentalists as a group
I believe that some of today’s social
problems could be cured by returning to a
1 2 3 4 5
more rural lifestyle in which people live in
harmony with the land
I feel that I have a lot in common with other
1 2 3 4 5
animal species
I like to garden 1 2 3 4 5
Being a part of the ecosystem is an important
1 2 3 4 5
part of who I am
I feel I have roots to a particular geographic
location that had a significant impact on my 1 2 3 4 5
development
Behaving responsibly toward the earth –
living a sustainable lifestyle – is a part of my 1 2 3 4 5
moral code
Learning about the natural world should be
1 2 3 4 5
an important part of every child’s upbringing
1
In general, being part of the natural world is
1 2 3 4 5
an important part of my self-image
I would rather live in a small room or house
with a nice view than a bigger room or house 1 2 3 4 5
with a view of other buildings
I really enjoy camping and hiking outdoors 1 2 3 4 5
Sometimes I feel like parts of nature –
certain trees, or storms, or mountains – have 1 2 3 4 5
a personality of their own
I would feel that an important part of my life
was missing if I was not able to get out and 1 2 3 4 5
enjoy nature from time to time
I take pride in the fact that I could survive
1 2 3 4 5
outdoors on my own for a few days
I have never seen a work of art that is as
beautiful as a work of nature, like a sunset or 1 2 3 4 5
a mountain range
My own interests seem to coincide with the
1 2 3 4 5
position advocated by environmentalists
I feel that I receive spiritual sustenance from
1 2 3 4 5
nature
I keep mementos from the outdoors in my
1 2 3 4 5
room, like shells or rocks or feathers
I take landscape photos including mountains,
1 2 3 4 5
forests, seas, nature and sunset

Environment Concern

Using a scale of 1 (strongly disagree) to 5 (strongly agree), please rate the extent to which you agree
or disagree with the following statements:

Strongly Strongly
Disagree Neutral Agree
Disagree Agree
We are approaching the limit of the
1 2 3 4 5
number of people the Earth can support
Humans have the right to modify the
1 2 3 4 5
natural environment to suit their needs
When humans interfere with nature it often
1 2 3 4 5
produces disastrous consequences
Human ingenuity will insure that we do
1 2 3 4 5
not make the Earth unlivable
Humans are seriously abusing the
1 2 3 4 5
environment
The Earth has plenty of natural resources if
1 2 3 4 5
we just learn how to develop them
Plants and animals have as much right as
1 2 3 4 5
humans to exist
The balance of nature is strong enough to
cope with the impacts of modern industrial 1 2 3 4 5
nations
Despite our special abilities, humans are
1 2 3 4 5
still subject to the laws of nature
2
The so-called “ecological crisis” facing
1 2 3 4 5
humankind has been greatly exaggerated
The Earth is like a spaceship with very
1 2 3 4 5
limited room and resources
Humans were meant to rule over the rest
1 2 3 4 5
of nature
The balance of nature is very delicate and
1 2 3 4 5
easily upset
Humans will eventually learn enough
about how nature works to be able to 1 2 3 4 5
control it
If things continue on their present course,
we will soon experience a major 1 2 3 4 5
ecological catastrophe

Childhood Participation in Nature

Urban

In which area did you spend most of your childhood? Suburban

Rural

Using a scale of 1 (never) to 4 (often), please answer the following questions by stating the frequency
with which you participated in the following nature-related activities:

Never Rarely Sometimes Often

How often did you participate in the following nature-
related activities before the age of 11?
Hiking, walking, or playing in the woods or natural areas 1 2 3 4
Camping 1 2 3 4
Hunting or fishing 1 2 3 4
Picking flowers, fruits, or vegetables from a garden 1 2 3 4
Planting trees, seeds or plants 1 2 3 4
Taking care of indoor or outdoor plants 1 2 3 4
Other, please specify: 1 2 3 4

Please answer the following questions by selecting "yes" or "no" for each question:

Yes No
Did you participate in the following activities before the age of 11?
Nature or environmental education in elementary school
Nature or environmental education outside of the school, such as through Boy Scouts, Girl
Scouts or summer camps
With whom did you spend time outdoors prior to the age of 11?
Parent or other significant adult
Teacher or school group
Sibling
Friend

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 Sources of Commitment to Environmental Protection

Please rank each of the following items by order of importance from 1 to 3 where 1 is the least
relevant to you and 3 the most relevant to you:

Self
Family
Organization

Responsible Environmental Waste Behavior

Using a scale from 1 (never) to 5 (always), please rate the frequency with which you do each of the
following:

Never Rarely Sometimes Often Always

How often do you separate your household
1 2 3 4 5
garbage?
How often do you use reusable containers to store
food rather than wrapping food in aluminum foil or 1 2 3 4 5
plastic wrap?
How often do you conserve water while washing
1 2 3 4 5
dishes?
How often do you conserve energy by turning off
1 2 3 4 5
light switches when leaving a room?
How often do you conserve water while brushing
your teeth, shaving, washing your hands, bathing, 1 2 3 4 5
etc.?
When disposing of durables like appliances,
furniture, clothing, linens, etc., how often do you
1 2 3 4 5
give that item to someone else, sell it to someone
else, or donate the item to a charitable organization?
How often do you refuse to buy products that you
1 2 3 4 5
feel have extensive packaging?
How often do you recycle your motor oil? 1 2 3 4 5
How often do you walk, ride a bike, or carpool to
1 2 3 4 5
work?

4
 Part B: Intention/Perception/Behavior Survey

B.1. Recycling

Environmental Knowledge
Using a scale of 1 (strongly disagree) to 5 (strongly agree), please rate the extent to which you agree
or disagree with the following statements:
Strongly Strongly
Disagree Neutral Agree
Disagree Agree

I don’t know why recycling is

1 2 3 4 5
important
Recycling reduces pollution 1 2 3 4 5
Recycling reduces wasteful use of
1 2 3 4 5
landfills
Recycling improves environmental
1 2 3 4 5
quality
Recycling saves energy 1 2 3 4 5
Recycling saves money 1 2 3 4 5
I know how to properly separate the
1 2 3 4 5
household waste
It is wrong to dispose recyclable and
1 2 3 4 5
non-recyclable waste together
Please answer the following questions by selecting "yes" or "no" for each question:
Yes No
There is a network to collect
recyclables in my community
I know what happens to the collected
recyclables in my community
Recyclables get mixed with other
trash in my community
Participating in recycling efforts
brings income
Please draw a line to match the correct bin:

5
Using a scale of 1 (strongly disagree) to 5 (strongly agree), please rate the extent to which you agree
or disagree with the following statements:

Strongly Strongly
Disagree Neutral Agree
Disagree Agree
Moral Obligation
It would be wrong of me not to recycle my
household waste if there was a proper 1 2 3 4 5
waste collection system in place
I would feel guilty about not recycling my
household waste if there was a proper 1 2 3 4 5
waste collection system in place
Not recycling goes against my principles 1 2 3 4 5
Everybody should share the responsibility
to recycle household waste if there was a 1 2 3 4 5
proper waste collection system in place
Attitude
Recycling is good 1 2 3 4 5
Recycling is useful 1 2 3 4 5
Recycling is rewarding 1 2 3 4 5
Recycling is responsible behavior 1 2 3 4 5
Recycling is sensible 1 2 3 4 5
Recycling is hygienic 1 2 3 4 5
Subjective Norm
My family expects me to separate waste 1 2 3 4 5
My neighbors expect me to separate waste 1 2 3 4 5
The community expects me to separate
1 2 3 4 5
waste
I will be more willing to recycle if my
1 2 3 4 5
neighbors recycle
I will stop recycling if my neighbors do not
1 2 3 4 5
participate in this effort
Perceived Behavioral Control
Whether I separate waste is dependent on
1 2 3 4 5
me
I separate waste regardless of whether
1 2 3 4 5
there are community incentives
Waste separation is a very easy thing for
1 2 3 4 5
me
Intention
I intend to separate my recyclables at home
on a regular basis if there are waste 1 2 3 4 5
collection measures
I intend to continue separating my
1 2 3 4 5
recyclables at home on a regular basis if

6
there are waste collection measures
I plan to participate in waste separation at
home if I am satisfied with the waste 1 2 3 4 5
collection measures by the local authorities
I will try my best to separate my
recyclables at home if I am convinced with 1 2 3 4 5
the benefits of waste separation at home
I will make an effort to separate my
recyclables at home if the local authority
1 2 3 4 5
enforces public participation in waste
separation at homes
I intend to separate my recyclables at home
if the local authority provides satisfactory 1 2 3 4 5
services for separated waste collection
Situational Factors
There are enough recycling bins near my
1 2 3 4 5
home
The activities for separate waste collection
1 2 3 4 5
in my area are well organized
There are satisfactory resources for
separate waste collection provided in my 1 2 3 4 5
area
There is enough space in my house to deal
1 2 3 4 5
with the separated waste
I have time to properly separate my waste 1 2 3 4 5
I know how to properly separate my waste 1 2 3 4 5
Having the local authority enforcing waste
separation at home would make me less 1 2 3 4 5
motivated to separate my waste at home
I get cooperation from other members of
1 2 3 4 5
the house in performing waste separation
Waste Behavior
I usually separate waste in accordance with
1 2 3 4 5
the requirements of the community
I have insisted on waste separation for
1 2 3 4 5
some time
I positively engage in waste separation 1 2 3 4 5

B.2. Waste Reduction

Using a scale of 1 (strongly disagree) to 5 (strongly agree), please rate the extent to which you agree
or disagree with the following statements:

7
 Strongly Strongly
Disagree Neutral Agree
Disagree Agree
Environmental Knowledge
Reducing my garbage helps decreasing
1 2 3 4 5
the amount of waste sent to landfills
Reducing my garbage helps protecting
1 2 3 4 5
the environment
Reducing garbage takes lots of time 1 2 3 4 5
Reducing garbage takes lots of planning 1 2 3 4 5
Reducing garbage takes lots of effort 1 2 3 4 5
Reducing garbage requires special skills 1 2 3 4 5
Moral Obligation
I feel I should not waste anything if it
1 2 3 4 5
could be used again
I should think about possible ways to
reduce the total amount of waste I 1 2 3 4 5
generate
Attitude
I like the idea of reducing my garbage 1 2 3 4 5
Reducing my garbage is important 1 2 3 4 5
Subjective Norm
People who are important to me think I
1 2 3 4 5
should reduce my garbage
Perceived Behavioral Control
Reducing my garbage is easy 1 2 3 4 5
I have to reduce my garbage 1 2 3 4 5
Intention
Over the next two weeks, I plan to
1 2 3 4 5
reduce my garbage
Situational Factors
Reducing my garbage fits with my daily
1 2 3 4 5
routine
I have time to reduce my garbage 1 2 3 4 5
Reducing my garbage takes too much
1 2 3 4 5
effort
Waste Behavior
I always attempt to reduce the amount of
1 2 3 4 5
waste in my home

8
Using a scale from 1 (never) to 5 (always), please rate the frequency with which you do each of the
following:

Never Rarely Sometimes Often Always

I take my own bag when going shopping,
1 2 3 4 5
rather than one provided by the shop
If I am offered a plastic bag in a store, I
1 2 3 4 5
will always take it
I reuse paper 1 2 3 4 5
I reuse glass bottles and jars 1 2 3 4 5
I reuse old plastic containers, like
1 2 3 4 5
margarine tubs
I use plastic knives, forks and spoons for
1 2 3 4 5
everyday life
I use plastic knives, forks and spoons for
1 2 3 4 5
special events at home
I use paper cups for everyday life 1 2 3 4 5
I use paper cups for special events at home 1 2 3 4 5

B.3. Composting

Using a scale of 1 (strongly disagree) to 5 (strongly agree), please rate the extent to which you agree
or disagree with the following statements:

Strongly Strongly
Disagree Neutral Agree
Disagree Agree
Environmental Knowledge
I know what items of household waste
1 2 3 4 5
can be composted
Organic waste can be partially treated at
1 2 3 4 5
home
I know how to compost my kitchen food
1 2 3 4 5
waste
Moral Obligation
It would be wrong of me not to treat part
of my organic waste if I learn how to 1 2 3 4 5
properly do it
Attitude
Household composting is favorable 1 2 3 4 5
Subjective Norm
My family expects me to compost my
1 2 3 4 5
kitchen food waste
My neighbors expect me to compost my
1 2 3 4 5
kitchen food waste
The community expects me to compost
1 2 3 4 5
my kitchen food waste

9
I will be more willing to compost if my
1 2 3 4 5
neighbors compost
I will stop composting if my neighbors do
1 2 3 4 5
not participate in this effort
Perceived Behavioral Control
Household composting is a very easy
1 2 3 4 5
thing for me
The decision to compost my food waste is
1 2 3 4 5
completely up to me
Intention
I am committed to treat part of my
organic waste if I learn the proper way to 1 2 3 4 5
do it
I am willing to get more information
about appropriate household waste 1 2 3 4 5
composting techniques
Situational Factors
I have time to compost my kitchen food
1 2 3 4 5
waste
Composting my kitchen food waste takes
1 2 3 4 5
a lot of effort
There is enough space in my house to
1 2 3 4 5
compost my kitchen food waste
Household compost bins have a strong
1 2 3 4 5
unpleasant smell
Household compost bins attract flies and
1 2 3 4 5
vermin
Household compost bins are unsightly 1 2 3 4 5
I have the necessary composting
1 2 3 4 5
equipment at home
Composting household waste is someone
1 2 3 4 5
else’s responsibility
Waste Behavior
I compost my garden/kitchen waste 1 2 3 4 5

Using a scale from 1 (never) to 5 (always), please rate the frequency with which you do each of the
following:

Never Rarely Sometimes Often Always

I mix my garden waste with the regular
1 2 3 4 5
waste

B.4. Current Waste Management System

Please answer the following questions by selecting "yes" or "no" for each question:

10
 Yes No
I trust my municipality’s system of waste collection/management
It is my municipality’s job/responsibility to find solutions to the waste problem in my
community
My municipality is handling the waste issue adequately

Male
Respondent Gender
Female
Respondent Age

11
 Part C: Health Survey

Civil Status and Residence Location Parent Parent Child Child Child Child Child Child Family History
1 2 1 2 3 4 5 6
Respondent
Civil status Single
Divorced
Widowed
Married
Gender Male
Female
Age (years)
Highest level of Primary - completed
education attained or less
Intermediate – some
or completed
Secondary or
Baccalaureate -
completed
Some college or
college degree
Graduate degree
(Masters/PhD)
Technical institute
(BT/TS)
Occupation Student
Employee
Retired
Unemployed
Homemaker
Business Owner
Type of job (if any)
Work location
Do you work near a Yes
dumpsite? No
Don’t know
Dumpsite distance 0-100
(m) 100-300
> 300
Do you live near a Yes
dumpsite? No
Don’t know
Dumpsite distance 0-100
(m) 100-300
> 300
For how long have
you lived in this
community?
Prior residence and
address
Number of years
lived in prior
residence

Residence Physical Description and Parent Parent Child Child Child Child Child Child Family History
Smoking Behavior 1 2 1 2 3 4 5 6
Height (cm)
Weight (kg)
Non-smoker
Smoking status Smoker
(cigarettes/day) Ex-smoker
Frequency
Smoking status Non-smoker

12
(narguileh/week) Smoker
Ex-smoker
Frequency
Yes
Do you exercise?
No
Which family member(s)
handles the waste at home?
(all that apply)
Who throws the garbage
outside? (all that apply)
Do you have a helper at Yes
home? No
Does s/he handle the waste Yes
at home? No
Does s/he throw the Yes
garbage outside? No
Yes
Do you raise poultry?
No
If yes, how many?
Own food
If yes, what do you feed
Buy special
them?
feed
Yes
Do you have a garden?
No
If yes, do you mix your Yes
garden waste with your
No
regular waste?
Well
Primary household water Public water
source supply
Tank
Gas
Home cooking fuel
Electricity
Gas
Electricity
Type of home heating
Diesel/Wood
heater
No separate
space
Kitchen space at home Separate
rooms
Outside
Presence of air conditioner Yes
at home No

Symptoms Parent 1 Parent 2 Child 1 Child 2 Child 3 Child 4 Child 5 Child 6 Family
History
Severity
Headache
scale (0-10)
Frequency #/month
Type Sinus
Migraine
Tensions
Cluster
Difficulty
concentrating
Dizziness/
vertigo
Memory
problems
Weakness in
hands and feet
Extreme
fatigue

13
Tremors
Nose irritation
Nosebleed
Pain in ears
Ringing or
buzzing in ears
Frequent sinus
blockage
Daily cough
Frequent colds
Wheezing
Chest tightness
or pain
Difficulty
breathing
Abdominal Frequency
pain (per month)
Nausea Frequency
(per month)
Unusual
Weight loss
Frequent
urination
Swelling of
legs and feet
Eye
irritation/tears
Blurred double
vision
Psychological Depression
symptoms Anxiety
Insomnia
Other
Sick child at
home within
the last 2
weeks
Other

Parent 1 Parent 2 Child 1 Child 2 Child 3 Child 4 Child 5 Child 6 Family

Skin diseases
History
Itchy
Skin problems
Non itchy
(rash)
Rash
Duration
Frequency of
Type of skin
attack (per
rash if
month)
diagnosed, i.e.
Drug used
utricaria
and use
frequency
Other allergies
Arthritis

Respiratory Diseases Parent 1 Parent 2 Child 1 Child 2 Child 3 Child 4 Child 5 Child 6 Family
History
Ear infection Frequency
(per year)
Acute Frequency
Bronchitis (per year)
COPD
Pneumonia Frequency
(per year)
Asthma Frequency of

14
(during the attacks (per
past year) month)
Severity of
attacks
(mild,
moderate or
severe)
Hospitalized
(per month)
Emergency
department
(per month)
Unscheduled
visit (per
month)
Treated at
home
Frequency of
inhaler usage
(per day)
Drug used in
treatment

Other Diseases Parent 1 Parent 2 Child 1 Child 2 Child 3 Child 4 Child 5 Child 6 Family
History
Hypertension
Heart attack
Anemia
Peptic ulcers
Hepatitis/liver
disease
Gallbladder
disease
Other GI
conditions
Diabetes
Other
endocrine
conditions
Tumor Benign
Malignant
Type
Low birth
weight
Cardiac
malformations
Neural tube
defect
External
genital
anomalies
Abdominal
wall defects
Cleft palate
and/or cleft lip
GIT anomalies
Urinary tract
anomalies
(including
kidneys)
Limb
reductions
anomalies
Other

15