General Info (ပံုမွန္အခ်က္အလက္မ်ား)

Date & Time of Survey (ေန႔စြဲႏွင့္အခ်ိန္)
Address (လိပ္စာ)
Type of home (အိမ္အမ်ိဳးအစား)
Picture (ဓါတ္ပံု)
Number of People (အိမ္ရွိလူဦးေရ)
Period of living in this home in years (ေနထိုင္ၿပီးေသာႏွစ္ကာလ)

Q&A (ေမးေျဖအပိုင္း)

Do you have a septic tank?

Type of Septic tank (အိမ္သာအမ်ိဳးအစား)

Size of septic tank in gallon. (ဂါလံျဖင့္ ကန္၏ အက်ယ္အဝန္း ခန္႔မွန္း)
Type of problem (ျဖစ္တတ္ေသာ ျပႆနာမ်ား)

If Other (တျခားဆိုလွ်င္)

Frequency of Problems (ျဖစ္ေသာအႀကိမ္အေရအတြက္)

Solutions of Problem (မည္သို႔ေျဖရွင္းခဲ့သနည္း)

Effectiveness of Problem Solving in percentage (ရာခိုင္ႏွဳန္းေျဖရွင္းမႈ)

Brand of Cleaning Product. (အသံုးျပဳေသာသန္႔ရွင္းေရးပစၥည္း)

Purchase Outlet? (သန္႔ရွင္းေရးပစၥည္းဝယ္ယူေသာေနရာ)

If other (တျခားဆိုလွ်င္)

Is there any other cleaning products or solutions that you wish to have? (တျခားေသာ သင့္အတြက္ လိုအပ္မည္ဟုထင္ေသာ သန္႔ရွင္းေရးပစၥည္း သို႔ ေျဖရွင္းရန္ျပႆနာ)

Will you be interested in testing an eco-green product that will solve the septic problem? (သင္သည္ ပတ္ဝန္းက်င္ကို အေထာက္အကူျပဳၿပီး အိမ္သာက်င္းျပႆနာကိုေျဖရွင္းေသာ ပစၥည္းကို စမ္းသပ္သံုးစြဲခ်င္ပါသလား)

If "Yes" when is the convenient day for testing? (စိတ္ဝင္စားပါက စမ္းသပ္ရန္ သင့္ေတာ္ေသာ ေန႔)

Surveyee's Signature (အိမ္ပိုင္ရွင္ သို႔ ေျဖဆိုသူ၏ လက္မွတ္)
Please note that this checklist is a hypothetical example and provides basic information only. It is not intended to take the place of, among other things, workplace, health and safety advice; medical advice, diagnosis, or treatment; or other applicable laws. You should also seek your own professional advice to determine if the use of such checklist is permissible in your workplace or jurisdiction.