Universal Systems Fresh Air Machine

Free Fresh Air Machine

Survey Open to West Virginia and Virginia Residence Only

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* 1. Since living in the area, do you believe the air has gotten:

Better

Worse

Stayed the Same

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* 2. Does anyone in your family suffer from:

Asthma

Allergies

Breathing Problems

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* 3. Do you have children or pets?

children

pets

both

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* 4. Are you married or have a partner that resides with you?

Yes

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* 5. What do you do for work?

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* 6. What does your spouse/partner do for work?

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* 7. Age Group

18-25

26-30

31-40

41-55

56-65

66-70

70+

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* 8. Do you own or rent?

own

rent

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* 9. Contact Information (We will contact you by phone)

Name

Address

City/Town

State/Province

ZIP/Postal Code

Phone Number

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* 1. Since living in the area, do you believe the air has gotten:

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* 2. Does anyone in your family suffer from:

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* 3. Do you have children or pets?

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* 4. Are you married or have a partner that resides with you?

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* 5. What do you do for work?

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* 6. What does your spouse/partner do for work?

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* 7. Age Group

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* 8. Do you own or rent?

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* 9. Contact ﻿Information (We will contact you by phone)

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* 10. Whose Facebook account did you see this on?

* 9. Contact Information (We will contact you by phone)