Clean Air Advocacy Engagement Survey

First Name

Last Name

Zip Code

Email

Which of the following tools or resources do you use to check outdoor air quality? (Please check all that apply.)

AirNow.gov
Outdoor air quality sensor at my home
Weather app
Local weather report
I do not check outdoor air quality
Other

If Other, please describe

Has anyone in your household experienced health impacts you believe were caused or made worse by poor outdoor air quality?

Yes

No

Unsure

If yes, how were you impacted? (ex: asthma flare-up, missed work/school, COPD symptoms triggered by wildfire smoke)

What, if any, past actions have you taken when you knew the outdoor air quality was at an unhealthy level? (Please check all that apply.)

Limit outdoor activity
Close windows and doors
Use indoor air cleaner
Carpool/take public transportation
Wear N95 mask
I have not been aware of poor air quality days
None
Other

If other, please describe

Which of these sources of outdoor air pollution do you feel have affected your life? (Please check all that apply.)

Local polluting infrastructure (power plants, manufacturing, etc.)
Wildfire smoke
Vehicle exhaust (cars, trucks, ships, etc.)
Other smoke sources (firepits, residential wood burning, etc.)
Unsure
None
Other

If other, please describe

What motivates you to care about air quality and lung health? (Please check all that apply.)

Lung disease, such as asthma or COPD, in my family
Protecting vulnerable populations (children, older adults, people with lung disease, etc.)
Lack of policies protecting air quality
Environmental impacts
Emergency preparedness
Quality of life concerns
Other

If other, please describe

We’d like to hear from you. By sharing your story, you help us show how poor air quality impacts real people and families. Your voice can help raise awareness, influence decision-makers, and build a stronger movement for clean air. Please use this section to share a little bit more about how air quality has affected you or your loved ones’ health and daily life.

Use these questions as a guide to help you get started:

What local sources of air pollution concern you most?

How has the health of you or your family been impacted?

What motivates you to want cleaner air in your neighborhood?

What changes would you like to see in your community to improve air quality?

Do you want to be contacted for future advocacy opportunities or training?

Yes

No

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