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 1, 2008.

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, please download the PDF version of this form, complete, and return via fax to 919-870-4801. If you complete the PDF version using Adobe Reader, please be aware that form data cannot be saved to your local hard drive using Adobe Reader. If you require additional help submitting the form, please call 919-707-5210.)To enable Javascript:

IE 6 or 7: 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. Type of Event (check all that apply): *

If the event/activity is among the following, please check next to the activity and enter the number of events/activities conducted, if applicable:

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?

2. 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 =

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

4. Did any professionals participating in this event / project receive continuing education credits? *

Yes No

If yes, please check all that apply below.

Physicians
Nurses
Registered Sanitarians / Environmental Health Specialists
Respiratory Therapists
Teachers
Public Health Professionals
Other (Enter up to 50 characters.)

5. Number of people impacted by this event, or estimated number in attendance: * (Enter number up to 4 digits.)

6. 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: dd/mm/yyyy; list month and year only as mm/yyyy, if event occurred on more than one day. Note: The event end date is optional. If applicable, for the end date you may enter the date or a short text description of no more than 10 characters, such as "present".)

7. Location of Event: *

City:

State:

County:

8. 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 or https://domain.extension. If possible, enter only the address to the top level/root of the site, such as http://www.asthma.ncdhhs.gov. If necessary (i.e., the web site does not have its own domain, enter the full path to the home page file or page, such as http://ncpublichealth.com/chronicdiseaseandinjury/index.htm.)

Optional Information

9. Funding Source for Event / Project:

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

Enter up to 250 characters. Characters Remaining =

10. 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:

11. 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 =

12. 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:

13. 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

Complete the reCAPTCHA image verification challenge below (if displayed) and press the "Submit" button. *

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.

Why are you being asked to complete the reCAPTCHA challenge? The reCAPTCHA, 3rd-party image verification tool helps identify the user as a human (rather than a spam-generating computer) and reduces the likelihood of this form being used for unintended purposes.

reCAPTCHA Quick Help:

If you use the audio challenge, type the numerals/digits without spaces (do not spell out the numbers).
If you use the image-based challenge each word you type should be separated by a space.
If you don't like your challenge, click the refresh button to the right of the response field to get a new one.
If you need further help, click the question mark ("?").

Why are there 2 words in the reCAPTCHA puzzle? A full summary can be found at http://recaptcha.net/learnmore.html. Solving the reCAPTCHA puzzle improves the process of digitizing scanned books by sending words that cannot be read by computers via Optical Character Recognition (OCR) to the Web in the form of CAPTCHAs for humans to decipher.

DHHS Disclaimer

Last Modified: Wednesday, November 4, 2009 11:28 AM