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

  Poor Alright Excellent
Scale

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

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

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* 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?

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

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

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?

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

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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:


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

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