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Air Quality Mobile Monitor Project - Interest Form

Wayne County Department of Health, Human & Veterans Services is launching a mobile air quality monitor program. This program will allow individuals diagnosed with asthma and their healthcare providers to better understand the air quality trends during asthma attacks. If you are an individual with asthma or a healthcare professional, please complete the following interest form to stay up to date on the program timeline and ways to participate.

1. First Name: *This question is required.

2. Last Name *This question is required.

3. Preferred method of communication *This question is required.Select all that apply

E-mail
Text

E-mail: *This question is required. This question requires a valid email address.

Phone Number: *This question is required.

4. Are you a healthcare provider, community health worker, or community organizer and interested in learning more about our Air Quality Community Health Champion Group to help with the Mobile Monitor Research study recruitment? *This question is required.

What is the name of the organization you represent? *This question is required.

Organization Zip Code *This question is required.

5. Are you interested in receiving a mobile air monitor? *This question is required.

Home Zip Code *This question is required.

Have you been diagnosed with any of the following: *This question is required.Select all that apply

Asthma
Chronic obstructive pulmonary disease (COPD)
Other Chronic Respiratory Illness
None of the above

6. What is your age? *This question is required.

7. Do you have access to reliable transportation to attend an in-person community event? *This question is required.

8. Are you interested in learning more about the mobile monitor project? *This question is required.