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NC Department of Health and Human Services
NC DPH: Chronic Disease and Injury Section
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The N.C. Asthma Environmental Survey

The Environmental Committee of the Asthma Alliance of North Carolina is collecting information on local and statewide activities that are related to the three environmental goals of the North Carolina Asthma Plan (PDF, 3.85 MB).

Goal 1: Identify and reduce exposure to indoor asthma triggers.
Goal 2: Identify and reduce exposure to outdoor asthma triggers.
Goal 3: Explore correlations between environmental exposure and health impact.

We would appreciate your help with the completion of this short questionnaire. Please complete one for each of your events/projects since January 2011.

Your feedback will be sent to North Carolina Asthma Program staff.

Thank you very much!

The N.C. Asthma Environmental Survey

Reporting Date (Today's Date):

1. Organization and Event Details: *

Primary Sponsoring Organization:
(Enter up to 100 characters.)

Partnering Organization(s):
(Enter up to 100 characters.)

Date(s) of the Event / Project:
(Format: mm/dd/yyyy. Note: The event end date is optional.)

(If you see this field, please leave it blank.)

2. Location of Event: *



3. Type of Event (check all that apply): *

Media Event or Campaign
Workshop / Training
Policy Decision Making / Implementation
Information Gathering / Survey
Professional Development
Conference / Meeting
Educational Materials / Website
Air Quality Flag Program
Coaches' Clipboard Program
Home Assessments - If checked, how many have you conducted?
Health Fair Display - If checked, how many have you conducted?
School Assessments - If checked, how many have you conducted?
Anti-Idling Campaign
Other (Enter up to 50 characters.)

4. Provide a brief description of the event, including its purpose, in the space below. Limit the description to 250 characters. *

Enter up to 250 characters. Characters Remaining =

5. Target Audiences (check all that apply): *

Parents / Families
Health Professionals
Lower Income / Underserved Communities
Seniors / Elderly
Racial / Ethnic Groups: (select a group from the sub-list)

African Americans
Native Americans
Other (Enter up to 50 characters.)

Other Target Audiences
(Enter up to 50 characters.)

6. Number of people impacted by this event, or estimated number in attendance: *

(Enter number up to 4 digits.)

Optional Information

7. Contacts/Resources:

Staff Contact Person(s) for this Event:
(Enter first and last name(s); separate names with commas)

Organization's Web Site:


Funding Source: Please provide the grant name and additional comments, if any; please limit comments to 250 characters.

Enter up to 250 characters. Characters Remaining =

8. Are you willing to be contacted as a reference for other organizations interested in conducting projects like yours? If so, please list contact phone number, mailing address, and email address.

Phone Number:
Format: ###-###-####

Mailing Address:

Enter up to 250 characters. Characters Remaining =

Email Address:

9. Additional Comments - If you have any additional comments, please enter them below. You may enter up to 500 characters.

Enter up to 500 characters. Characters Remaining =

10. Would you like to be included in the AANC listserv for statewide asthma-related announcements and updates? If so, please provide your email address (even if you provided it in question 10).

Email Address:

11. If you have examples of materials used during the event/project, feel free to attach them electronically to email. Hard copies of materials can be sent to the following address or fax number:

AANC Environmental Committee
c/o N. C. Asthma Program
1915 Mail Service Center
5505 Six Forks Road
Raleigh, NC 27699-1915
Fax: 919-870-4801

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