Air Quality Report (health)
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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.
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Location of Report *
Address or cross streets
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.
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.
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
Email or phone contact
This field is optional it may show up publicly
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