Safer Air Box

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Safer Air Box

Thanks for your interest in getting a Safer Air Box for your home! Please fill out the following questions so we can coordinate getting you one.

Full Name *

Today’s Date *

YYYY

Address & Zip Code *

Location of Outreach or Event (ex. Frandelja, Alice Griffith, etc.)

Phone Number *

Do you or any of the people you live with have any of the following respiratory health issues? (Select all that apply) *

None

Asthma

Occupational Lung Disease

Cystic Fibrosis

Lung Cancer

Tuberculosis Type B

Bronchitis

COPD

Sleep Apnea

High Blood Pressure

Diabetes

Other:

Required

Does your household include any of the following: *

People who are 65 years and older

People who are 17 and younger

Someone with a disability

None

Required

Does your home have a HVAC system (Heating, Ventilation, Air Condition)
*

Yes

Do you work an occupation that exposes your to potential harmful health effects? *

Yes

Which method do you prefer to receive messages about turning on the air filter and changing the filters? *

Text

Call

Social media platforms

Box Number (Located on Sticker- ONLY for giving out filters)

Submit

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