Soot Exposure Survey
Help us assess your exposure to soot and any related health effects. Please answer all questions as accurately as possible.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Age
*
Gender
*
Male
Female
Non-binary/Other
What is your primary environment of exposure?
*
Home
Workplace
Outdoors
Other
How often are you exposed to soot?
*
Daily
A few times a week
A few times a month
Rarely
Never
How long have you been exposed to soot in total?
*
Please Select
Less than 6 months
6 months to 2 years
2 to 5 years
More than 5 years
Please indicate if you have experienced any of the following symptoms in the past 12 months due to soot exposure.
*
Rows
Never
Rarely
Sometimes
Often
Coughing
1
2
3
4
Shortness of breath
5
6
7
8
Eye irritation
9
10
11
12
Skin irritation
13
14
15
16
Headaches
17
18
19
20
Fatigue
21
22
23
24
Rate your overall concern about the health effects of soot exposure.
*
1
2
3
4
5
Do you use any protective equipment when exposed to soot?
*
Yes, regularly
Yes, occasionally
No
If you have any additional comments or details about your soot exposure, please share them below.
Submit Survey
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