Home Health Assessment

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Home > Associations > States > WASHINGTON > Local Programs > Air Quality > Forms

Your Information

Name:

First Required	Last Required

Email: Required

Street 1: Required

Street 2:

City/State/ZIP:

City Required	State Required	ZIP Required

Phone Number:

Gender:

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Question - Not Required - Asthma, Allergies, Mold, Tobacco Use

	Is there a child in the home with asthma?
	Do you or anyone in the household have asthma?
	Do you or anyone in the household have allergies?
	Do you have mold in your house?
	Do you or anyone in your household use tobacco?

Question - Not Required - How many adults in your household?

Question - Not Required - How many children in your household?

Question - Not Required - Do you have pets? How many? What kind?

(Maximum response 255 chars, approx. 5 rows of text)

Question - Not Required - Concerns/Why are you requesting a Home Assessment?

Question - Not Required - How did you hear about us?

Question - Not Required - Income

Question - Not Required - Refugee, Immigrant

	Refugee
	Immigrant

Question - Not Required - Age

Question - Not Required - Race American Indian
Asian American
African American
Pacific Islander
Multi-Racial
Other
Caucasian

Question - Not Required - Disabled

Question - Not Required - Limited English

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