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Air Quality Survey
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1.
WHO REFERRED YOU?
(Required.)
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2.
DOES ANYONE IN YOUR HOUSEHOLD SUFFER FROM ASTHMA, ALLERGIES, OR BREATHING PROBLEMS?
(Required.)
Yes
No
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3.
DO YOU HAVE CHILDREN/PETS?
(Required.)
Children
Pets
Both
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4.
ARE YOU MARRIED OR HAVE A LIVE-IN PARTNER?
(Required.)
Yes
No
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5.
WHAT IS YOUR CURRENT OCCUPATION?
(Required.)
6.
WHAT IS YOUR PARTNERS OCCUPATION?
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7.
AGE GROUP
(Required.)
18-25
26-29
30-39
40-49
50-59
60-69
OTHER
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8.
HOUSING STATUS
(Required.)
OWN
RENT
LIVE WITH FAMILY
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9.
YOUR NAME
(Required.)
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10.
ADDRESS (INCLUDE CITY AND STATE)
(Required.)
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11.
PHONE NUMBER
(Required.)
