Universal Systems Fresh Air Survey

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

Comment Box

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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. Annual Household Income

Under 25,000

25,000 - 40,000

Over 40,000

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* 6. What do you do for work?

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

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* 8. Interested in a job?

Full Time

Part Time

Not Interested

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* 9. Age group?

18-25

26-30

31-40

41-55

56-65

66-70

70+

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* 10. Do you own or rent:

own

rent

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* 11. Contact information: (we will contact you by phone)

Name

Address

City/Town

State/Province

ZIP/Postal Code

Phone Number

Question Title

* 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. Annual Household Income

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* 6. What do you do for work?

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

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* 8. Interested in a job?

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* 9. Age group?

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* 10. Do you own or rent:

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* 11. Contact information: (we will contact you by phone)

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* 12. Who sent you? (first and last name)