Air Quality Report (health)
MAKE SURE YOU SEE THE CONFIRMATION PAGE AFTER YOU SUBMIT
Please fill form out for each individual.
ONLY include new symptoms since the occurrence.
You may put short details in the "other" box once its checked.
All fields are mandatory.
Form results will be made public.
Location of Report *
Address or cross streets
Your answer
Did you hear a noise and what kind? *
Check all that apply
Required
Date and time of incident *
MM
/
DD
/
YYYY
Time
:
Did you smell anything? *
Odor
Required
Name *
One report per person. You may put anonymous if you like.
Your answer
Did you feel a head ache *
Required
Do you have a scratchy or sore throat? *
Required
Eyes Irritants *
Required
Do you have lung Issues? *
This is only regarding changes since the incident
Required
Are you experiencing fatigue? (tiredness) *
add details in other box
Required
Numbness or tingling *
Required
Have you experienced a fever? *
Required
Skin irritations *
Required
Psychological *
Required
Please breifly explain any other symptoms.
Your answer
Civil Defense and doctors treatment is to get out of the affected area. Do you have a place to go? *
Required
Did you recieve evacuation orders? *
civil defense or otherwise
Required
At the time of the occurance were your intoxicated *
Required
Medical Attention *
Required
Public Attitude *
Required
I attest that this is my true experience. *
sign or mark that you are telling the truth
Your answer
Email or phone contact
This field is optional it may show up publicly
Your answer
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