Complete a separate form for each individual service.  When you have completed this form for one service and exited from the form, just click on the link for the form again and repeat for each additional service.   

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* 1. In which rooms and indoor spaces licensed for use by children is it NOT possible to keep fresh air moving through? (tick all those that apply)

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* 2. Does your service need an air purifier now? 

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* 3. Will winter increase your service's need for an air purifier?

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* 4. A carbon dioxide (CO2) monitor is useful to find which rooms have good fresh air flow and which ones don’t.  Does your service need a CO2 monitor?

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* 5. What city or town is your service located in? 

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* 6. Is your service

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* 7. If you have indicated above that your service needs an air purifier and/or a CO2 monitor, do you give permission for your service's name to be included in our request list published online and provided to the Ministry of Education?

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* 8. What is the name of your service?  (this question is optional)

Ka mau te wehi!  Thank you for completing this survey and letting us know your service's needs.

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