Name
*
First Name
Last Name
Date of Birth
*
MM
DD
YYYY
Male or Female
Male
Female
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
What county do you live in?
*
Email
*
Home Phone
(###)
###
####
Cell Phone
*
(###)
###
####
Do you send and receive text messages?
*
Yes
No
Primary Phone
Cell Phone
Home Phone
Who is your current employer?
Are there any job-related chemical risk or hazards? If yes, please explain
Spouse or Secondary Contact Person
Secondary Contact Phone Number
How long have you owned your home?
Approximately how old is your home?
To your knowledge, has your home been tested for radon? If yes, what were the findings?
Do you experience excess dust at your home?
*
Yes
No
Still Unsure
If so, how frequently?
Once every 2 months
Once every month
Once every week
Once every day
Does dust accumulate inside or outside your home?
Inside
Outside
Both
If dust accumulates inside of your home, please list in which locations.
If dust accumulates on your property, where does it accumulate (Select all that apply)
Does your home have an attic or crawlspace?
Do you have a well on your property?
Yes
No
If you have a well on your property, what is it used for? (Check all that apply)
What is the depth of the well on your property?
Have you noticed anything unusual about the water from the well? (Taste, smell, color, etc.)
Yes
No
Where do you obtain your drinking water?
Where do you get your water for clothes washing, showering, and gardening?
How many people live in your home?
*
Do children live in your home?
Yes
No
If children live in the home, what are their ages? If children previously lived in the home, please list the dates.
Has anyone living in the home been diagnosed with any cancers?
Yes
No
If anyone has been diagnosed with any cancers, please list what types of cancers and where in the body.
Do you or your spouse smoke? If yes, how long?
Do you, your spouse, your child, or any other family member have diseases or problems with the following? (If yes, please select who and what)
Do you, your spouse, your child, or any other family member ever have any of the following issues? (If yes, please select who and what)
If yes above, please elaborate.
Do you, your spouse, your child, or any other family member have asthma, allergies or lung problems? (If yes, please select who and what)
If yes above, please elaborate.
Are you aware that your home is built near a current or former phosphate mine and processing facility?
Yes
No
Would you be willing to grant our team permission to collect samples on your property and/or inside your home?
*
Yes
No
Will you allow our team to collect samples in the following locations? (Check all that apply)
What days would be best to schedule testing? (Check all that apply)
What time of the day would be best for testing?
Do you have any additional comments or concerns?
