Citizen Survey and Complaint Form
for Oil and Gas Industrial
Problem: Excessive noise associated
with oil and natural gas extraction activities.
Purpose: This form has been created to gather citizen
complaints and bring them to the proper agencies and to push for action to address noise problems.
1. Is noise related to oil and
gas extraction a problem for you and/or other family members? __Yes __No
If yes, please answer the following questions.
2. Approximately how long has
the noise(s) been a nuisance?
______________ month(s) / year(s)
Location of equipment or compressor(s) producing noise if known: (well
site number/ company name)
Please indicate level of the
noise below: Rate frequency of occurrence
using #1 for never, through #5 for continuous
noise is not a nuisance at all
__ Moderately loud
__ Uncomfortably loud
5. Does the noise interfere with sleep? __Yes __No
Do you know whom to call for noise or other gas and oil industry complaints? __Yes __No
Please list contact:
7. Have you
attempted to address a noise problem relating to oil and gas activities near
your residence? __ Yes __No
If yes, please describe and
indicate whether or not your attempt resolved the noise problem.
8. Are you interested in
participating in an effort to resolve noise problems with oil and gas
extraction? If so, please provide contact
Phone: _____________________________________ Email:
Thank you for taking the time to participate in this
Should you wish
to write additional comments, use the backside of this paper and/or use
additional paper as needed.
9. Can you be contacted for
additional information or questions?
__Yes __ No