Student Activity Sheets - Grades 3-5 Page 13
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20Air Pollution Home Survey
Activity 9:
Take this questionnaire home and fill it out with your family.
Page 1 of 2
Name:__________________________________________
Date:_________________________
POTENTIAL POLLUTERS
3. Does anyone in your family regularly take
public transportation?
1. Put a check next to the products you find in
a. no
your home with the words “Hazardous,”
b. yes
“Toxic,” “Danger,” “Caution,” or “Warning.”
H
Spray Paint
H
Paint Remover
H
4. Does anyone in your family regularly
Lighter Fluid
walk or bicycle or skate instead of
H
Bug Spray
use a car to run errands?
H
Window Cleaner
a. no
H
Furniture Polish
b. yes
H
Drain Opener
H
Disinfectant
5. Does your family try to run several
H
Cleanser
errands at one time when taking
H
the car?
Aerosol Hair Spray
a. no
H
Aerosol Deodorant
b. yes
H
Nail Polish
c. don’t own a car
H
Nail Polish Remover
H
Air Freshener
6. Is your car well-maintained?
H
Fabric Softener Sheets
a. no
H
Other:
b. yes
c. don’t own a car
7. Do you avoid “topping off” your gas tank?
a. no
DRIVING
b. yes
c. don’t own a car
2. Does anyone in your family regularly carpool?
a. no
8. Does your family often shop by phone, mail,
or Internet?
b. yes
a. no
b. yes
13
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