NC Asthma Program: NC Asthma Environmental Activity Survey

Datos Básicos sobre el Asma

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!

If there is an asterisk "*" at the end of a question, it means an answer is required. We encourage responses to all questions.

In order to complete this evaluation, you must have a Javascript-enabled browser. If a Javascript-enabled browser is not available to you or you require additional help, please call 919-707-5213.)To enable Javascript:

Internet Explorer: Tools >> Internet Options >> Security Tab >> Custom Level >> Scripting - Active Scripting - Select "Enable" >> Click OK >> Click "Yes" when warned/asked if you want to change security settings for this zone >> Click "OK" again >> Refresh this page in your browser and you should be able to use the form below.

Firefox: Tools >> Options >> Content >> Select the "Enable Javascript" checkbox >> Click OK >> Reload this page in your browser and you should be able to use the form below.

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.)

2. Location of Event: *

City:

State:

County:

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

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): *

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: format: http://www.google.com

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 via 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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As noted above, you need to enable Javascript in your browser in order to use this form. If that is not possible or is troublesome, you may recommend this site using your local, client-based email program or a web-based email program. Return to the Asthma Home Page.

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Last Modified: Thursday, September 8, 2011 1:17 PM