Asthma Advocates in Action

Survey Purpose and Description

* Is your family impacted by asthma?

* Do you want to meet other people affected by asthma to learn from each other and share tips?

* Do you want to learn more about programs available to help people with asthma?

* Are you interested in free leadership trainings to gain advocacy and professional skills?

The Rhode Island Department of Health’s Asthma Control Program is seeking to work with and support individuals and families who are affected by asthma. Please fill out this short survey to be eligible for future opportunities, such as peer support groups or free leadership trainings.

By sending this survey you will share these responses with Julian Rodríguez-Drix, the Asthma Program Manager at the RI Department of Health. This survey will be used for informational and educational purposes only, in order to better serve people with asthma in Rhode Island. Any personal information volunteered will not be shared with any advertisers and will be kept private.

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* 1. Full name:

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* 2. Age:

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* 3. Phone Number:

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* 4. Email address:

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* 5. Mailing address:

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* 6. Do you personally have asthma?

Yes

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* 7. Are you a parent and/or caregiver for someone with asthma?

Yes

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* 8. Have you participated in any of the following asthma interventions or programs? (check all that apply)

Asthma Camp

Asthma home visiting program

Draw A Breath, or other asthma self-management programs or classes

Breathe Easy At Home (referral to code enforcement to require landlord action on repairs to fix asthma triggers)

Other (please specify)

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* 9. Are you interested in any of the following (check all the apply)

Free leadership training to empower yourself and others to create change

Peer support group for families impacted by asthma

Improving Public Housing Authority policies for residents with asthma

Improving Public School policies for people with asthma

Participating in the RI Asthma Control Coalition

Other (please specify)

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* 10. How has asthma impacted your life or your family? (optional)

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* 11. What is your main concern about asthma? (optional)

Thank you for your responses. You may be contacted by the Department of Health or one of our designated community partners to ask if you are interested in participating in any of the opportunities listed. If you have any questions you can email Julian.Drix@health.ri.gov or call (401) 222-7742.

Thank you - Together, we can improve quality of life for all people with asthma!