Here's the Official Head Gasket Survey Form.

For your convenience, Karl Bloss has created a webpage Survey Form with
drop-down answers, etc., which you may complete by going to:
http://www.enter.net/~bloss/vw/headsurvey/

Alternatively, simply hit the "Reply" button, type the appropriate
numeric response to the left of each question-line below (each line is a
separate question, except where ^^^ or ---> appear), and then simply hit
the "send" button.

Thanks for your participation.
_________________________________________________________________
___________ H E A D  G A S K E T   S U R V E Y   F O R M ______
 TYPE ONLY NUMERIC RESPONSES IN LEFT-SIDE COLUMN

        Year of Vehicle 83(1)  84(2)  85(3)  86(4)  87(5)  88(6)  89(7)
90(8) 91(9)
        Model: not know(1) PasVan(2)  Wkendr(3)  Westy(4)  Sync(5)
-------->        Sync Wkedr(6)   Sync Westy(7)
       Odometer Units Miles: (1)  Kilometers (2)
       Current Odometer reading
       Odometer Reading When Head Leaks First Appeared ("0" if no leaks)

       Odometer Reading When Head Gaskets Replaced ("0" if never
replaced")
       Odometer Reading When Gaskets "Failed" [Vehicle not drivable)("0"
if not  apply)
^^^^^^^^^
       Od. Reading when First Experienced Overheating Problems ("0" if
never)
       Od. Reading When Radiator Sealant First Used ("0" if never)
^^^^^
XXX[DISCREPREWEBPAGENOENTRYHERE]XXX
       Number of Times Sealant Used
       Type : N/A(1) Ceramic(2)  Alumaseal(3) Prestone(4) Barsleak(5)
Other(6) MIX(7)
       Od. Reading When Sealant Stopped Working (separate entry for each
such event)
^^^^^^^^
       Coolant Type : Phosphate (1)  No Phosphate (2)  VW(3)  Mix(4)
       Water Type:  Hard Tap(1) Soft Tap(2) Distilled(3)  de-ionized(4)
       Coolant Change: every 6 mos.(1)  yearly(2)  2 yrs(3)  3 yrs.(4),
Never(5) Unknown(6)
       Average Low winter Temperature (specify F.(1)  or C.(2))
       Average High summer temperture (specify F.(1)  or C.(2))
^^^^^^^^
        Usage: Daily(1)   Several time per week(2)   Weekly(3)   Monthly
(4)
        Average mi/km per year
        Driving Type: Mostly town(1)  mostly highway(2)  equal mix(3)
        Principal Driver Style:  Gentle(1)  Average(2)   Aggressive(3)
        Short Trips of Ten Mins. or Less: Daily(1) Weekly(2)
Rarely/Never(3)
        Mins. warm vehicle Up before driving in winter
        Mins. warm vehicle Up before driving in warmer (+50F.) weather
^^^^^^
        Heads were: Never Replaced/Repaired(1)  Replaced w/rebuilts(2)
-------->     Coated(3)  Machined&Resurfaced(4)  Left as is(5)
        Heads were coated with: N/A(1) JB Weld (2)  ceramic (3)
--------->    Other ___________(4)
        What was the TOTAL (approx.) cost to repair/replace/coat leaky
heads
        How Many mi/km now on the coated heads.
        Have you ever had the gaskets fail with coated heads Y(1) N(2)
        Have you ever had head gaskets leak with coated heads Y(1)N(2).
        Type of coating where gaskets leaked or failed: N/A(1) JB
Weld(2)
--------->  Ceramic(3)  Pure Alumnium (e.g. Boston)(4) Other
_________(5)
        How many mi./km before coated heads leaked/failed.
^^^^^^^
        If your gaskets failed/leaked, did you install a rebuilt engine
Y(1)N(2)
        What was the TOTAL cost to install the rebuilt engine, incl.
labor.
        How many miles now on rebuilt engine
        How many mi./km. before rebuilt engine heads leaked ("0" if
never).
        How many mi./km before rebuilt engine head gaskets failed

        Have you ever checked your ground wires: Yes (1) No (2)
        Have you ever found that your ground wires required
cleaning/mait. Y(1) N(2)
        Have You Augmented the Ground Wires at Engine/Head/Frame: Yes
(1) no (2)
        Does your van have rust: None(1) very light(2)  light(3)
moderate(4)  heavy(5)
        Is the van garage Kept:  Yes (1)  No (2)

COMMENTS :

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