Please answer the following questions about the perceived indoor air quality in your home:

Question Title

* 1. Using the scale below, how would you rate the Indoor Air Quality in your home?

	Poor				Alright					Excellent
Scale	Scale Poor	Scale	Scale	Scale	Scale Alright	Scale	Scale	Scale	Scale	Scale Excellent

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* 2. What is the approximate square footage of your home (only the heated and cooled areas)?

500 sqft - 1000 sqft

1000 sqft - 3000 sqft

3000 sqft - 5000 sqft

5000 sqft - 10000 sqft

10000 sqft+

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* 3. From the concerns listed below, please select all that apply:

A member of my household wakes up with puffy eyes or sinus congestion

A member of my household has trouble sleeping through the night

Cooking odors (fried foods, vegetables, fish) linger in my house

Second hand smoke or smoke odor is present in my home

Pet odors or Pet dander are present in my home

Visible mold or mildew is present in my home

I worry about bacteria being present on surfaces and in the air

I care for an elderly parent in my home

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* 4. Do any of these allergens bother a member of the household?

dust/dust mites

mold

pet dander

pollen

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* 5. Do any of these chemicals bother a member of the household?

disinfectant sprays

household cleaners

perfumes/colognes

Other (please specify)

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* 6. Do you believe Indoor Air Quality problems might be contributing to sickness or allergic reactions in your home?

Yes

Please provide any additional information here:

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* 7. Do you currently have some sort of air filter or air purifier running in your home?

Yes

If Yes, please specify which make / model.

If you rated your home between a one to seven, or are experiencing health problems you probably want to continue gathering data. We can assist you in assessing your home by providing you with an assessment kit that includes two samples (additional samples could be included). Areas assessed will include heating/cooling systems, general living areas, and moisture prone areas. Surface samples will be sent to a laboratory for analysis quantifying common indoor contaminants within your home.

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* 8. Do you want to improve the Indoor Air Quality in your home?

Yes

Please provide any additional information here:

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* 9. Do you want your home assessed, and have samples taken for laboratory analysis?

Yes

Please provide any additional information here:

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* 10. Thank you for filling out this survey.
If you wish for us to contact you, or you are wanting to schedule an indoor air quality assessment, please share your relevant contact information below:

Name:

Company:

Address:

Address 2:

City/Town:

State:

ZIP/Postal Code:

Email Address:

Phone Number:

Be sure to click the "Done" button located below and to the right of this text to complete the survey.

Question Title

* 1. Using the scale below, how would you rate the Indoor Air Quality in your home?

Question Title

* 2. What is the approximate square footage of your home (only the heated and cooled areas)?

Question Title

* 3. From the concerns listed below, please select all that apply:

Question Title

* 4. Do any of these allergens bother a member of the household?

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* 5. Do any of these chemicals bother a member of the household?

Question Title

* 6. Do you believe Indoor Air Quality problems might be contributing to sickness or allergic reactions in your home?

Question Title

* 7. Do you currently have some sort of air filter or air purifier running in your home?

Question Title

* 8. Do you want to improve the Indoor Air Quality in your home?

Question Title

* 9. Do you want your home assessed, and have samples taken for laboratory analysis?

Question Title

* 10. Thank you for filling out this survey.If you wish for us to contact you, or you are wanting to schedule an indoor air quality assessment, please share your relevant contact information below:

* 10. Thank you for filling out this survey.
If you wish for us to contact you, or you are wanting to schedule an indoor air quality assessment, please share your relevant contact information below: