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Weekly Report
Tracking water related illness for your health and safety
1.
What was the date and time you went into the water?
2.
How would you describe the weather at the time?
Please select
Sunny
Cloudy
Rainy
Snowy
Foggy
Severe (e.g. Thunderstorm, Lightning, Tornado, etc)
3.
What color was the water?
Please select
Clear
Blue
Green
Brown
Murky
Steel Grey
Cloudy
Blackish
Reddish / Rusty
Other/Unsure
4.
What does the water smell like?
Please select
I didn't notice
Fresh
Fishy
Sewage
Chemical
Unsure
5.
Who is this report about?
Please select
Adult
Child
Dog
Horse
Sealife
Birds
6.
What type of water activity were you performing? (Choose one or more)
Select Activities
Swimming
Fishing
Dragon Boating
Surfing
Sailing
Waka Ama
Kayaking
Paddleboarding
Wading
White Baiting
Diving
Jet-skiing
Water Skiing
Canoeing
Water Aerobics
Wind Surfing
Snorkelling
Powerboat Racing
6.
What type of activity was your pet doing? (Choose one or more)
Select Activities
Dog Walking
Playing in Water
Swimming (Pet)
Drinking Water
Fetching in Water
Running Along Shore
Digging in Sand
Rolling in Water
Wading (Pet)
Contact with Algae
Other
7.
What location did you go to?
Please select
Cannons Creek Pool
Days Bay
Dolly Varden Beach
Duck Creek
Eastbourne Beach
Frank Kitts Park
Freyberg Pool and Fitness Centre
Fulton Swim School
H2O Xtream Aquatic Centre
Huia Pool
Island Bay
Ivey and Browns Bay Paramata
Karori Pool
Keith Spry Pool
Khandallah Pool
Karehana Bay
Lyall Bay
Makara Beach
Mana Marina
Onepoto Ramp
Oriental Bay
Oriental Parade
Paremata Bridge (mana foreshore)
Petone Beach
Plimmerton Beach
Plimmerton Boating Club
Pukerua Bay
Red Rocks (Pariwhero)
Scorching Bay
Seatoun Beach
Stokes Valley Pool
Tawa Pool
Te Ngaengae Pool
Te Rauparaha Arena and Aquatic Centre
Thorndon Pool
Titahi Bay
Wellington Regional Aquatic Centre (WRAC)
Wineera Foreshore
Somewhere else but within the area
8.
Do you live near the location of activity?
Yes
No
9.
What is your status?
Please select
Ratepayer
Resident
Other
10.
Did you feel sick after activity?
Yes
No
11.
What symptoms appeared after activity? (Choose one or more)
Select Symptoms
Ear Aches
Ear Infection
Headaches
Fever
Loose Stools
Rashes on Body
Mouth Ulcers
Blisters near Mouth/Nose
Nausea
Eye Irritation
Respiratory
Stomach Cramps
Vomiting
Body Sores
11.
What symptoms did your pet have after activity? (Choose one or more)
Select Pet Symptoms
Vomiting
Diarrhoea
Skin Irritation
Eye Irritation
Lethargy / Low Energy
Excessive Drooling
Breathing Issues
Seizure
Other
12.
How many hours after the activity did the symptoms start (within 7 days)?
13.
Approximately how many days did your symptoms last (within 30 days)?
14.
What is your sex?
i
Please select
Male
Female
Prefer not to say
15.
What is your ethnicity?
Please select
European (Pākehā)
Māori
Asian
Pacifika
Middle Eastern
Latin American
African
Others
Prefer not to say
16.
How old are you?
i
17.
Have you been diagnosed by a Doctor?
Yes
No
18.
Is it a Communicable Disease?
Yes
No
Submit