Home
About Us
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.
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 location did you go to?
Please Select
Dolly Varden Beach
Karehana Bay
Onepoto Ramp
Paremata Bridge (mana foreshore)
Pukerua Bay
Titahi Bay
Wineera Foreshore
Mana Marina
Plimmerton Boating Club
Ivey and Browns Bay Paramata
Plimmerton Beach
Te Rauparaha Arena and Aquatic Centre
Cannons Creek Pool
Duck Creek
Somewhere else but within the area
7.
Do you live near the location of activity?
Yes
No
8.
What is your status?
Please select
Ratepayer
Resident
Other
9.
Did you feel sick after activity?
Yes
No
10.
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.
How many hours after the activity did the symptoms start (within 7 days)?
12.
Approximately how many days did your symptoms last (within 30 days)?
13.
What is your sex?
i
Please select
Male
Female
Prefer not to say
14.
What is your ethnicity?
Please select
European (Pākehā)
Māori
Asian
Pacifika
Middle Eastern
Latin American
African
Others
Prefer not to say
15.
How old are you?
i
16.
Have you been diagnosed by a Doctor?
Yes
No
17.
Is it a Communicable Disease?
Yes
No
Submit