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Universal Systems Fresh Air Survey
Free Fresh Air Machine
Survey open to West Virginia and Virginia residence ONLY
OK
*
1.
Since living in the area, do you believe the air has gotten:
(Required.)
better
worse
stayed the same
*
2.
Does anyone in your family suffer from:
(Required.)
asthma
allergies
breathing problems
Comment Box
*
3.
Do you have children or pets?
(Required.)
children
pets
both
*
4.
Are you married or have a partner that resides with you?
(Required.)
Yes
No
*
5.
Annual Household Income
(Required.)
Under 25,000
25,000 - 40,000
Over 40,000
*
6.
What do you do for work?
(Required.)
7.
What does your spouse/partner do for work?
*
8.
Interested in a job?
(Required.)
Full Time
Part Time
Not Interested
*
9.
Age group?
(Required.)
18-25
26-30
31-40
41-55
56-65
66-70
70+
10.
Do you own or rent:
own
rent
*
11.
Contact information: (we will contact you by phone)
(Required.)
Name
Address
City/Town
State/Province
ZIP/Postal Code
Phone Number
*
12.
Who sent you? (first and last name)
(Required.)
Current Progress,
0 of 12 answered
