What type of dwelling do you live in?
Apartment
Townhouse
House
Duplex (multi-family home)
Organic Farm
Nonorganic Farm
Where is your home located? (check what applies)
Urban
Suburban
Rural Agricultural
Rural Non-Agricultural
Near a pollution producing structure (bus station, factory, waste site, etc)
When was your home built?
After 1978
Before 1978
Before 1970
I don't know
Have you tested the paint on your walls or windowsills?
yes, it tested positive, but was cleaned up
yes, it tested positive and is not yet cleaned
yes, it tested negative
No
Do you have an attached garage?
Yes
No
Are the doors between the house and garage weatherstripped?
Yes
No
Not applicable
Check all rooms that have wall-to-wall carpets.
Bedrooms
Living or family rooms
Bathrooms
None
Check what you have on your windows.
Curtains
Pleated Shades
Vinyl miniblinds
None
Do you wipe your feet on a doormat or remove your shoes upon entering your home?
Never
Sometimes
Always
Check the following items you use dust mite covers on.
My mattress
Children's mattress
My pillows
Children's pillows
None
What age are your non-adult children? (check all that apply)
0-2 years
3-6 years
7-11 years
12-18 years
I have no children
I have no children, but children are/will be in my home regularly
Do any of your children have asthma?
Yes
No
No children at home
Check all toys that you purchase for your children.
Arts & crafts
Wooden toys
Cloth toys
Stuffed animals
Rubber or soft plastic toys
Hard plastic toys
Board Games
How often do you wash or freeze stuffed animals?
About once per month
2-3 times per year
Rarely or never
My child does not have stuffed animals
Does your house have any of the following? (check all that apply)
Not applicable
Wooden deck or wooden patio
Outdoor wooden playset or wooden sandbox
Wooden flower boxes
