Exit this survey Work-Related Asthma Survey To better ensure that the information on this web-page is relevant to all visitors, please take a couple minutes to complete an anonymous survey. Your name and identity will not be associated with any of the answers. Thank you in advance for your time. Please provide the following information about yourself. Question Title * 1. Gender: Male Female Question Title * 2. What is your age? 18 to 24 25 to 34 35 to 44 45 to 54 55 to 64 65+ Question Title * 3. Please check the box that best describes you. Adult with asthma Spouse or partner of an adult with asthma Relative of an adult with asthma Co-worker of an adult with asthma Friend of an adult with asthma Other, Please Specify Question Title * 4. Are you a New York State Resident? Yes No If not, in which state do your currently reside? The next five questions are intended for adults with asthma, if you do not have asthma please skip to question #11. Question Title * 5. Does your asthma get worse soon after starting work? Yes No Don't Know/Not Sure Question Title * 6. Has a doctor, nurse or other health professional ever told you that you have asthma? Yes No Don't Know/Not Sure Question Title * 7. Do you try to avoid certain activities at work because they make your asthma get worse? Yes No Don't Know/Not Sure Question Title * 8. Did your asthma begin soon after breathing something irritating at work? Yes No Don't Know/Not Sure Question does not apply to me Question Title * 9. Were you ever told by a doctor, nurse or other health professional that your asthma was related to any job you ever had? Yes No Don't Know/Not Sure Question Title * 10. Did you ever tell a doctor, nurse or other health professional that your asthma was related to any job you had? Yes No Don't Know/Not Sure Question Title * 11. How useful did you find the information and links on this web-site? not at all useful a little bit useful somewhat useful useful very useful not at all useful a little bit useful somewhat useful useful very useful Question Title * 12. Were you able to find the asthma information you were looking for on the web-site? Yes No Question Title * 13. Please use the space below to submit any additional comments or questions. Done
