We would like to ask for your help to get a better insight on how people view the severity

of what's going on in our world today

. As part of that, we would like to ask a few

questions about asthma and how much you know

. We thank you for taking the time to fill

this out and would appreciate your honesty

.

1 .

Basic Information

Age: / !

Sex

: / 1

Race/Ethnicity :l~~ 5 ~if i l

2.

Do you have asthma, or do you know anyone who has asthma?

[,cj Yes

[ ]No

3 .

How important is air pollution as being a trigger for asthma?

[1]

[2]

[3]

[41

[51

Not at all important

Extremely important

4 .

What can people do to reduce the triggers for asthma in the air?

i.-'Adults

should avoid smoking indoors when someone with asthma lives there,

4nd look for other sources of indoor gases (ovens, etc

.).

/Individuals

should make sure all indoor surfaces are regularly cleaned or

1

,vacuumedCommunities .

should identify sources of fine particulate pollution

(diesel exhaust, etc

.)

'Illinois IEPA should eliminate sources of pollution that contribute to asthma

.

/ }h

Address

:

~JZ(

J

1~ ~~

Name:

CLEAN AIR QUESTIONNAIRE

HAROLD WASHINGTON COLLEGE

AUTUMN, 2006

RECEIVED

CLE'S OFFICE

FEQ 0 5 2007

Pollution

STATE OF

Control

ILLINOIS

Board

---

CLEAN AIR QUESTIONNAIRE

HAROLD WASHINGTON COLLEGE

AUTUMN, 2006

We would like to ask for your help to get a better insight on how people view the severity

of what's going on in our world today . As part of that, we would like to ask a few

questions about asthma and how much you know . We thank you for taking the time to fill

this out and would appreciate your honesty .

1 .

Basic Information

Age:19 Sex : F

Race/Ethnicity: 5n j'

2 .

Do you have asthma, or do you know anyone who has asthma?

[ I

[ ] No

3 .

How important is air pollution as being a trigger for asthma?

[1]

[2]

[3]

[4]

1

Not at all important

Extremely important

4.

What can people do to reduce the triggers for asthma in the air?

Name:

Address:

Adults should avoid smoking indoors when someone with asthma lives there,

.,and look for other sources of indoor gases (ovens, etc .).

Individuals should make sure all indoor surfaces are regularly cleaned or

yactfumed .

Communities should identify sources of fine particulate pollution

esel exhaust, etc .)

Illinois IEPA should eliminate sources of pollution that contribute to asthma

.

/\/I

na / f IcrJT

JoM S Avpr toe L

---

CLEAN AIR QUESTIONNAIRE

HAROLD WASHINGTON COLLEGE

AUTUMN, 2006

We would like to ask for your help to get a better insight on how people view the severity

of what's going on in our world today . As part of that, we would like to ask a few

questions about asthma and how much you know

. We thank you for taking the time to fill

this out and would appreciate your honesty .

I .

Basic Information

Age: I

q

Sex : M

-

Race/Ethnicity :Lu J-i nv

2

.

Do you have asthma, or do you know anyone who has asthma?

NYes

[ ] No

3 .

How important is air pollution as being a trigger for asthma?

[1]

[2]

[3]

[5]

Not at all important

Extremely important

4 .

What can people do to reduce the triggers for asthma in the air?

Adults should avoid smoking indoors when someone with asthma lives there,

and look for other sources of indoor gases (ovens, etc

.).

Individuals should make sure all indoor surfaces are regularly cleaned or

vacuumed.

Communities should identify sources of fine particulate pollution

(diesel exhaust, etc.)

Illinois IEPA should eliminate sources of pollution that contribute to asthma

.

NameAddress

:

:

(

4

,?

AI

I V 3 S- AvP

~_-

---

CLEAN AIR QUESTIONNAIRE

HAROLD WASHINGTON COLLEGE

AUTUMN, 2006

We would like to ask for your help to get a better insight on how people view the severity

of what's going on in our world today . As part of that, we would like to ask a few

questions about asthma and how much you know . We thank you for taking the time to fill

this out and would appreciate your honesty .

Basic Information

Age

:

c

~

Sex :

r1

Race/Ethnicity :

t

11. /} S

;1 i

,

2.

Do you have asthma, or do you know anyone who has asthma?

[ ]

Yes

[>] No

3.

How important is air pollution as being a trigger for asthma?

[11

[2]

[3]

41J

[5]

Not at all important

Extremely important

4.

What can people do to reduce the triggers for asthma in the air?

Adults should avoid smoking indoors when someone with asthma lives there,

and look for other sources of indoor gases (ovens, etc .).

Individuals should make sure all indoor surfaces are regularly cleaned or

vacuumed.

Communities should identify sources of fine particulate pollution

(diesel exhaust, etc.)

__ Illinois IEPA should eliminate sources of pollution that contribute to asthma

.

Name

:

IIV

Address:

---

CLEAN AIR QUESTIONNAIRE

HAROLD WASHINGTON COLLEGE

AUTUMN, 2006

We would like to ask for your help to get a better insight on how people view the severity

of what's going on in our world today . As part of that, we would like to ask a few

questions about asthma and how much you know

. We thank you for taking the time to fill

this out and would appreciate your honesty .

1 .

Basic Information

Age: Il

Sex:

--f

Race/Ethnicity :

Z3kc1

C-

2.

Do you have asthma, or do you know anyone who has asthma?

[v]'Yes

[ ] No

3

.

How important is air pollution as being a trigger for asthma?

[1]

[2]

[3]

[4]

Not at all important

Extr

important

4.

What can people do to reduce the triggers for asthma in the air?

L-Adults should avoid smoking indoors when someone with asthma lives there,

and look for other sources of indoor gases (ovens, etc .).

Individuals should make sure all indoor surfaces are regularly cleaned or

t/vacuumedCommunities

.

should identify sources of fine particulate pollution

t/Illinois

diesel exhaust,

IEPA should

etc .)eliminate

sources of pollution that contribute to asthma

.

Name:

Address :

`^ 1 'I /

-JL&Oil?

---

CLEAN AIR QUESTIONNAIRE

HAROLD WASHINGTON COLLEGE

AUTUMN, 2006

We would like to ask for your help to get a better insight on how people view the severity

of what's going on in our world today

. As part of that, we would like to ask a few

questions about asthma and how much you know

. We thank you for taking the time to fill

this out and would appreciate your honesty .

I .

Basic Information

Age: Sex: Race/Ethnicity :

2 .

Do you have asthma, or do you know anyone who has asthma?

['V]

Yes

[ ] No

3.

How important is air pollution as being a trigger for asthma?

[1]

[2]

[3]

[4]

[5]

Not at all important

Extremely important

4.

What can people do to reduce the triggers for asthma in the air?

V Adults should avoid smoking indoors when someone with asthma lives there,

and look for other sources of indoor gases (ovens, etc .)

.

Individuals should make sure all indoor surfaces are regularly cleaned or

vacuumed.

Communities should identify sources of fine particulate pollution

(diesel exhaust, etc.)

v'

Illinois IEPA should eliminate sources of pollution that contribute to asthma

.

Name:

Address :

---

CLEAN AIR QUESTIONNAIRE

HAROLD WASHINGTON COLLEGE

AUTUMN, 2006

We would like to ask for your help to get a better insight on how people view the severity

of what's going on in our world today . As part of that, we would like to ask a few

questions about asthma and how much you know

. We thank you for taking the time to fill

this out and would appreciate your honesty .

Basic Information

Age: - Sex: Race/Ethnicity

: !i

2 .

Do you have asthma, or do you know anyone who has asthma?

[ ''] Yes

[ ] No

How important is air pollution as

being a trigger for asthma?

[1]

[2]

[3]

[4]

[5]

Not at all important

Extremely important

4.

What can people do to reduce the triggers for asthma in the air?

v

Adults should avoid smoking indoors when someone with asthma lives there,

and look for other sources of indoor gases (ovens, etc

.).

Individuals should make sure all indoor surfaces are regularly cleaned or

vacuumed.

Communities should identify sources of fine particulate pollution

(diesel exhaust, etc .)

Illinois IEPA should eliminate sources of pollution that contribute to asthma

.

Name:

L-

a li „'

t l '-

1

Address :

1

)"V C

---

Name :

Address:

CLEAN AIR QUESTIONNAIRE

HAROLD WASHINGTON COLLEGE

AUTUMN, 2006

We would like to ask for your help to get a better insight on how people view the severity

of what's going on in our world today . As part of that, we would like to ask a few

questions about asthma and how much you know

. We thank you for taking the time to fill

this out and would appreciate your honesty .

Basic Information

Age :

!O

Sex :

r~

Race/Ethnicity :

2.

Do you have asthma, or do you know anyone who has asthma?

`(q Yes

[ ] No

3.

How important is air pollution as being a trigger for asthma?

[1]

[2]

[3]

[4]

Not at all important

W

Extremely important

4.

What can people do to reduce the triggers for asthma in the air?

'f

Adults should avoid smoking indoors when someone with asthma lives there,

and look for other sources of indoor gases (ovens, etc .) .

Individuals should make sure all indoor surfaces are regularly cleaned or

V

Communities

vacuumed.

should identify sources of fine particulate pollution

V' (diesel exhaust, etc .)

Illinois IEPA should eliminate sources of pollution that contribute to asthma

.

FVrN ~ ~44(Vrc~

---

CLEAN AIR QUESTIONNAIRE

HAROLD WASHINGTON COLLEGE

AUTUMN, 2006

We would like to ask for your help to get a better insight on how people view the severity

of what's going on in our world today . As part of that, we would like to ask a few

questions about asthma and how much you know . We thank you for taking the time to fill

this out and would appreciate your honesty .

Basic Information

Age:,I~A

Sex: "

Race/Ethnicity : \-\. C-

2 .

Do you have asthma, or do you know anyone who has asthma?

0

Yes

[ ] No

How important is air pollution as being a trigger for asthma?

[1]

[2]

[3]

[4]

Not at all important

[5]

Extremely important

4.

What can people do to reduce the triggers for asthma in the air?

Adults should avoid smoking indoors when someone with asthma lives there,

and look for other sources of indoor gases (ovens, etc .).

_ Individuals should make sure all indoor surfaces are regularly cleaned or

vacuumed.

Communities should identify sources of fine particulate pollution

(diesel exhaust, etc .)

Illinois IEPA should eliminate sources of pollution that contribute to asthma .

Name:

Ylt

Y'y1

rr 4.,{~

) C

Address:

---

CLEAN AIR QUESTIONNAIRE

HAROLD WASHINGTON COLLEGE

AUTUMN, 2006

We would like to ask for your help to get a better insight on how people view the severity

of what's going on in our world today

. As part of that, we would like to ask a few

questions about asthma and how much you know . We thank you for taking the time to fill

this out and would appreciate your honesty .

I .

Basic Information

Age:

Sex : ( Race/Ethnicity : ,

2 .

Do you have asthma, or do you know anyone who has asthma?

[ ] Yes

[v4'No

3 .

How important is air pollution as being a trigger for asthma?

[1]

[2]

[3]

[4]

[51

Not at all important

Extremely important

4.

What can people do to reduce the triggers for asthma in the air?

Adults should avoid smoking indoors when someone with asthma lives there,

and look for other sources of indoor gases (ovens, etc .).

Individuals should make sure all indoor surfaces are regularly cleaned or

vacuumed .

Communities should identify sources of fine particulate pollution

(diesel exhaust, etc .)

~_ Illinois IEPA should eliminate sources of pollution that contribute to asthma

.

Name:

Address

:

---

Name:

Address :

CLEAN AIR QUESTIONNAIRE

HAROLD WASHINGTON COLLEGE

AUTUMN, 2006

We would like to ask for your help to get a better insight on how people view the severity

of what's going on in our world today . As part of that, we would like to ask a few

questions about asthma and how much you know

. We thank you for taking the time to fill

this out and would appreciate your honesty .

I .

Basic Information

2

.

Age: "

j Sex: `t'1 Race/Ethnicity :

Do you have asthma, or do you know anyone who has asthma?

[v] Yes

[ ]No

3.

How important is air pollution as being a trigger for asthma?

[1]

[2]

[3]

f(9

[5]

Not at all important

Extremely important

4.

What can people do to reduce the triggers for asthma in the air?

Adults should avoid smoking indoors when someone with asthma lives there,

and look for other sources of indoor gases (ovens, etc .).

Individuals should make sure all indoor surfaces are regularly cleaned or

vacuumed

.

Communities should identify sources of fine particulate pollution

`J Illinois

(diesel exhaust,

IEPA should

etc.)eliminate

sources of pollution that contribute to asthma

.

---

CLEAN AIR QUESTIONNAIRE

HAROLD WASHINGTON COLLEGE

AUTUMN, 2006

We would like to ask for your help to get a better insight on how people view the severity

of what's going on in our world today

. As part of that, we would like to ask a few

questions about asthma and how much you know

. We thank you for taking the time to fill

this out and would appreciate your honesty .

Basic Information

Age:9.C,

Sex:

1V,

Race/Ethnicity : "n ,' ,I

[L

'

A

2 .

Do you have asthma, or do you know anyone who has asthma?

[ ] Yes

[ t4 No

How important is air pollution as being a trigger for asthma?

[1]

[2]

[3]

[4]

[5],,

Not at all important

Extremely important

4 .

What can people do to reduce the triggers for asthma in the air?

Adults should avoid smoking indoors when someone with asthma lives there,

T

and look for other sources of indoor gases (ovens, etc

.).

Individuals should make sure all indoor surfaces are regularly cleaned or

vacuumed.

Communities should identify sources of fine particulate pollution

(diesel exhaust, etc .)

Illinois IEPA should eliminate sources of pollution that contribute to asthma

.

Name:

IlCctl U r

Address:

~~ ( Vt

---

CLEAN AIR QUESTIONNAIRE

HAROLD WASHINGTON COLLEGE

AUTUMN, 2006

We would like to ask for your help to get a better insight on how people view the severity

of what's going on in our world today

. As part of that, we would like to ask a few

questions about asthma and how much you know . We thank you for taking the time to fill

this out and would appreciate your honesty .

1 .

Basic Information

Age: Sex: ('l Race/Ethnicity

:h

2.

Do you have asthma, or do you know anyone who has asthma?

c~]

Yes

[ ]

No

3 .

How important is air pollution as being a trigger for asthma?

[1]

[2]

Not at all important

[3]

[4]

Extremely important

4.

What can people do to reduce the triggers for asthma in the air?

Adults should avoid smoking indoors when someone with asthma lives there,

and look for other sources of indoor gases (ovens, etc .).

Individuals should make sure all indoor surfaces are regularly cleaned or

vacuumed.

Communities should identify sources of fine particulate pollution

(diesel exhaust, etc.)

Illinois IEPA should eliminate sources of pollution that contribute to asthma .

Name :

Address:

---

Name :

~ i S'

(

-

I,~PS ~1Ci

Y

It

1

Ly _~

\ Ili W)(-11

1

Address :

C

CLEAN AIR QUESTIONNAIRE

HAROLD WASHINGTON COLLEGE

AUTUMN, 2006

W e would like to ask for your help to get a better insight on how people view the severity

of what's going on in our world today

. As part of that, we would like to ask a few

questions about asthma and how much you know . We thank you for taking the time to fill

this out and would appreciate your honesty .

I .

Basic Information

Age: /,),% Sex: ; Race/Ethnicity : r^~~CQr' IC

( 1 ,

jf -

2 .

Do you have asthma, or do you know anyone who has asthma?

[ ] Yes

Q~No

3.

How important is air pollution as being a trigger for asthma?

[1]

[2]

[3]

[4]

[5]

Not at all important

Extre efy important

4.

What can people do to reduce the triggers for asthma in the air?

w Adults should avoid smoking indoors when someone with asthma lives there,

,and look for other sources of indoor gases (ovens, etc .).

1/Individuals

~`acuumedshould

.

make sure all indoor surfaces are regularly cleaned or

.V

Communities should identify sources of fine particulate pollution

lesel exhaust, etc .)

Illinois IEPA should eliminate sources of pollution that contribute to asthma .

---

CLEAN AIR QUESTIONNAIRE

HAROLD WASHINGTON COLLEGE

AUTUMN, 2006

We would like to ask for your help to get a better insight on how people view the severity

of what's going on in our world today . As part of that, we would like to ask a few

questions about asthma and how much you know

. We thank you for taking the time to fill

this out and would appreciate your honesty .

1 .

Basic Information

Age:j

',

Sex: P '\t

Race/Ethnicity : t

2.

Do you have asthma, or do you know anyone who has asthma?

[ ] Yes

[ i] No

How important is air pollution as being a trigger for asthma?

[1]

[2]

[3]

[4]

Not at all important

[5]

Extremely important

4.

What can people do to reduce the triggers for asthma in the air?

Adults should avoid smoking indoors when someone with asthma lives there,

and look for other sources of indoor gases (ovens, etc .).

Individuals should make sure all indoor surfaces are regularly cleaned or

vacuumed .

Communities should identify sources of fine particulate pollution

(diesel exhaust, etc.)

Illinois IEPA should eliminate sources of pollution that contribute to asthma .

Name: U+--

1

Address :

S 1

---

[l]

Not at all important

Name :

Address

:

CLEAN AIR QUESTIONNAIRE

HAROLD WASHINGTON COLLEGE

AUTUMN, 2006

We would like to ask for your help to get a better insight on how people view the severity

of what's going on in our world today

. As part of that, we would like to ask a few

questions about asthma and how much you know . We thank you for taking the time to fill

this out and would appreciate your honesty .

Basic Information

Age: Sex :

i'

Race/Ethnicity : -

2 .

Do you have asthma, or do you know anyone who has asthma?

[ ] Yes

[J] No

How important is air pollution as being a trigger for asthma?

4.

What can people do to reduce the triggers for asthma in the air?

Adults should avoid smoking indoors when someone with asthma lives there,

and look for other sources of indoor gases (ovens, etc .) .

Individuals should make sure all indoor surfaces are regularly cleaned or

vacuumed.

~'

Communities should identify sources of fine particulate pollution

(diesel exhaust, etc .)

Illinois IEPA should eliminate sources of pollution that contribute to asthma .

[2]

[3]

[4]'

[5]

Extremely important

---

CLEAN AIR QUESTIONNAIRE

HAROLD WASHINGTON COLLEGE

AUTUMN, 2006

We would like to ask for your help to get a better insight on how people view the severity

of what's going on in our world today

. As part of that, we would like to ask a few

questions about asthma and how much you know

. We thank you for taking the time to fill

this out and would appreciate your honesty

.

Basic Information

Age : ~'

Sex : /q

Race/Ethnicity :

2.

Do you have asthma, or do you know anyone who has asthma?

Yes

7

[ ]No

H

C

ow important is air pollution as being a trigger for asthma?

[1]

[2]

[3]

[4]

[5]~

Not at all important

Extre 1y important

4.

What can people do to reduce the triggers for asthma in the air?

Adults should avoid smoking indoors when someone with asthma lives there,

and look for other sources of indoor gases (ovens, etc

.).

Individuals should make sure all indoor surfaces are regularly cleaned or

vacuumed.

Communities should identify sources of fine particulate pollution

(diesel exhaust, etc

.)

Illinois IEPA should eliminate sources of pollution that contribute to asthma

.

Name

: .-P-1-74" o5

Address:

---

CLEAN AIR QUESTIONNAIRE

HAROLD WASHINGTON COLLEGE

AUTUMN, 2006

We would like to ask for your help to get a better insight on how people view the severity

of what's going on in our world today . As part of that, we would like to ask a few

questions about asthma and how much you know

. We thank you for taking the time to fill

this out and would appreciate your honesty

.

1 .

Basic Information

Age:

Race/Ethnicity : H,%r l f-

2.

Do you have asthma, or do you know anyone who has asthma?

["]"Yes

[ ]No

3.

How important is air pollution as being a trigger for asthma?

[1]

[2]

[3]

[4]

[5]

Not at all important

Extremely important

4.

What can people do to reduce the triggers for asthma in the air?

Adults should avoid smoking indoors when someone with asthma lives there,

and look for other sources of indoor gases (ovens, etc

.).

Individuals should make sure all indoor surfaces are regularly cleaned or

vacuumed .

`' Communities should identify sources of fine particulate pollution

(diesel exhaust, etc.)

Illinois IEPA should eliminate sources of pollution that contribute to asthma

.

Name

:

Address :

---

CLEAN AIR QUESTIONNAIRE

HAROLD WASHINGTON COLLEGE

AUTUMN, 2006

We would like to ask for your help to get a better insight on how people view the severity

of what's going on in our world today

. As part of that, we would like to ask a few

questions about asthma and how much you know . We thank you for taking the time to fill

this out and would appreciate your honesty .

Basic Information

Age: Sex : Race/Ethnicity :

2 .

Do you have asthma, or do you know anyone who has asthma?

[

J

Yes

[ ]

No

3.

How important is air pollution as being a trigger for asthma?

i

[1]

[2]

[3]

[4]

[5]

Not at all important

Extremely important

4.

What can people do to reduce the triggers for asthma in the air?

Adults should avoid smoking indoors when someone with asthma lives there,

and look for other sources of indoor gases (ovens, etc .).

Individuals should make sure all indoor surfaces are regularly cleaned or

vacuumed.

Communities should identify sources of fine particulate pollution

(diesel exhaust, etc.)

` Illinois IEPA should eliminate sources of pollution that contribute to asthma

.

Name:

CVa

Address:

---

CLEAN AIR QUESTIONNAIRE

HAROLD WASHINGTON COLLEGE

AUTUMN, 2006

We would like to ask for your help to get a better insight on how people view the severity

of what's going on in our world today . As part of that, we would like to ask a few

questions about asthma and how much you know

. We thank you for taking the time to fill

this out and would appreciate your honesty .

Basic Information

Age

:rl _

Sex :

1 ' Race/Ethnicity

:

Address :

2 .

Do you have asthma, or do you know anyone who has asthma?

[ ]Yes

[J] No

How important is air pollution as being a trigger for asthma?

Lll

[2]

[31

[41

Not at all important

[5]

'

Extremely important

4.

What can people do to reduce the triggers for asthma

in the air?

Adults should avoid smoking indoors when someone

and look for other sources of indoor gases (ovens,

V Individuals should make sure all indoor surfaces

vacuumed.

Communities should identify sources of fine

(diesel exhaust, etc.)

Illinois IEPA should eliminate sources of pollution

{

with asthma lives there,

etc.).

are regularly cleaned or

particulate pollution

that contribute to asthma.

Name:

1 ?

; J

---

CLEAN AIR QUESTIONNAIRE

HAROLD WASHINGTON COLLEGE

AUTUMN, 2006

We would like to ask for your help to get a better insight on how people view the severity

of what's going on in our world today . As part of that, we would like to ask a few

questions about asthma and how much you know

. We thank you for taking the time to fill

this out and would appreciate your honesty .

I .

Basic Information

Age :

[5'

Sex

:

,

Race/Ethnicity :Z5ivk f

2.

Do you have asthma, or do you know anyone who has asthma?

[ ] Yes

r

[~ No

3.

How important is air pollution as being a trigger for asthma?

[1]

[2]

[3]

[4]

[5] l

Not at all important

Extremely important

4.

What can people do to reduce the triggers for asthma in the air?

Adults should avoid smoking indoors when someone with asthma lives there,

and look for other sources of indoor gases (ovens, etc .).

Individuals should make sure all indoor surfaces are regularly cleaned or

vacuumed.

Communities should identify sources of fine particulate pollution

(diesel exhaust, etc.)

Illinois IEPA should eliminate sources of pollution that contribute to asthma

.

Name

:

Address:

---

CLEAN AIR QUESTIONNAIRE

HAROLD WASHINGTON COLLEGE

AUTUMN, 2006

We would like to ask for your help to get a better insight on how people view the severity

of what's going on in our world today . As part of that, we would like to ask a few

questions about asthma and how much you know

. We thank you for taking the time to fill

this out and would appreciate your honesty .

Basic Information

Age : Sex: Race/Ethnicity :

2.

Do y9u have asthma, or do you know anyone who has asthma?

Yes

[ ]No

How important is air pollution as being a trigger for asthma?

[I]

[2]

[3]

[4]

0] 1

Name

:

Address :

Not at all important

4.

What can people do to reduce the triggers for asthma in the air?

Adults should avoid smoking indoors when someone with asthma lives there,

and look for other sources of indoor gases (ovens, etc

.) .

Individuals should make sure all indoor surfaces are regularly cleaned or

vacuumed .

Communities should identify sources of fine particulate pollution

(diesel exhaust, etc.)

6' Illinois IEPA should eliminate sources of pollution that contribute to asthma .

Extremely important

---

CLEAN AIR QUESTIONNAIRE

HAROLD WASHINGTON COLLEGE

AUTUMN, 2006

We would like to ask for your help to get a better insight on how people view the severity

of what's going on in our world today

. As part of that, we would like to ask a few

questions about asthma and how much you know

. We thank you for taking the time to fill

this out and would appreciate your honesty

.

Basic Information

Age:

I ~i

Sex: Race/Ethnicity

:

2 .

Do you have asthma, or do you know anyone who has asthma?

[ ]Yes

N1

No

3 .

How important is air pollution as being a trigger for asthma?

[1]

[2]

[3]

[4])

[5]

Not at all important

Extremely important

4 .

What can people do to reduce the triggers for asthma in the air?

Name:

V

Jl' 5

Address:

r

Adults should avoid smoking indoors when someone with asthma lives there,

and look for other sources of indoor gases (ovens, etc .).

Individuals should make sure all indoor surfaces are regularly cleaned or

vacuumed.

Communities should identify sources of fine particulate pollution

(diesel exhaust, etc.)

Illinois IEPA should eliminate sources of pollution that contribute to asthma

.

---

CLEAN AIR QUESTIONNAIRE

HAROLD WASHINGTON COLLEGE

AUTUMN, 2006

We would like to ask for your help to get a better insight on how people view the severity

of what's going on in our world today

. As part of that, we would like to ask a few

questions about asthma and how much you know . We thank you for taking the time to fill

this out and would appreciate your honesty .

1 .

Basic Information

Age: - Sex : Race/Ethnicity :

2 .

Do you have asthma, or do you know anyone who has asthma?

[ ] Yes

[ ]

No

How important is air pollution as being a trigger for asthma?

[1]

[2]

d]~

[4]

[5]

Not at all important

Extremely important

4.

What can people do to reduce the triggers for asthma in the air?

Adults should avoid smoking indoors when someone with asthma lives there,

and look for other sources of indoor gases (ovens, etc .).

Individuals should make sure all indoor surfaces are regularly cleaned or

vacuumed.

Communities should identify sources of fine particulate pollution

(diesel exhaust, etc .)

Illinois IEPA should eliminate sources of pollution that contribute to asthma .

Name: 1AC' -

Address:

)_ L,

,

---

2 .

Not at all important

CLEAN AIR QUESTIONNAIRE

HAROLD WASHINGTON COLLEGE

AUTUMN, 2006

We would like to ask for your help to get a better insight on how people view the severity

of what's going on in our world today . As part of that, we would like to ask a few

questions about asthma and how much you know . We thank you for taking the time to fill

this out and would appreciate your honesty .

Basic Information

Age: 1

'1

Sex :

Race/Ethnicity :#/ Pbic

Do you have asthma, or do you know anyone who has asthma?

[ ]No

How important is air pollution as

being a trigger for asthma?

[3]

[4]

4 .

What can people do to reduce the triggers for asthma in the air?

X

Adults should avoid smoking indoors when someone with asthma lives there,

and look for other sources of indoor gases (ovens, etc .) .

Individuals should make sure all indoor surfaces are regularly cleaned or

vacuumed.

Communities should identify sources of fine particulate pollution

(diesel exhaust, etc .)

Illinois IEPA should eliminate sources of pollution that contribute to asthma .

Name:

Address:

,ed4ehe

Alvarez

---

CLEAN AIR QUESTIONNAIRE

HAROLD WASHINGTON COLLEGE

AUTUMN, 2006

We would like to ask for your help to get a better insight on how people view the severity

of what's going on in our world today

. As part of that, we would like to ask a few

questions about asthma and how much you know

. We thank you for taking the time to fill

this out and would appreciate your honesty

.

1 .

Basic Information

Age:

Sex :

Race/Ethnicity :

2.

Do you have asthma, or do you know anyone who has asthma?

[ ] Yes

[ ]

No

3

.

How important is air pollution as being a trigger for asthma?

[1]

[2]

[31

[4]

[5]

Not at all important

Extremely important

4.

What can people do to reduce the triggers for asthma in the air?

Adults should avoid smoking indoors when someone with asthma lives there,

and look for other sources of indoor gases (ovens, etc

.) .

Individuals should make sure all indoor surfaces are regularly cleaned or

vacuumed .

Communities should identify sources of fine particulate pollution

(diesel exhaust, etc.)

Illinois IEPA should eliminate sources of pollution that contribute to asthma

.

Name:

Address :

---

CLEAN AIR QUESTIONNAIRE

HAROLD WASHINGTON COLLEGE

AUTUMN, 2006

We would like to ask for your help to get a better insight on how people view the severity

of what's going on in our world today

. As part of that, we would like to ask a few

questions about asthma and how much you know . We thank you for taking the time to fill

this out and would appreciate your honesty .

1 .

Basic Information

Age: Race/Ethnicity

:

a

La( f

2 .

Do you have asthma, or do you know anyone who has asthma?

[ ] Yes

`[ 'I

No

3 .

How important is air pollution as being a trigger for asthma?

[1]

[2]

[3]

[4]

Not at all important

[5]

Extremely important

4 .

What can people do to reduce the triggers for asthma in the air?

Adults should avoid smoking indoors when someone with asthma lives there,

and look for other sources of indoor gases (ovens, etc

.)

.

T Individuals should make sure all indoor surfaces are regularly cleaned or

vacuumed

.

Communities should identify sources of fine particulate pollution

(diesel exhaust, etc.)

Illinois IEPA should eliminate sources of pollution that contribute to asthma

.

Name:

}K,V-

Address :

C

---

Name:

Address :

CLEAN AIR QUESTIONNAIRE

HAROLD WASHINGTON COLLEGE

AUTUMN, 2006

We would like to ask for your help to get a better insight on how people view the severity

of what's going on in our world today . As part of that, we would like to ask a few

questions about asthma and how much you know . We thank you for taking the time to fill

this out and would appreciate your honesty .

1 .

Basic Information

Age: Sex: f

Race/Ethnicity :' ,

t

\ ci,r t)»'Pvi, "

d'-

2 .

Do you have asthma, or do you know anyone who has asthma?

[ ] Yes

[c+No

3 .

How important is air pollution as being a trigger for asthma?

[1]

[2]

[3]

[4]

Not at all important

'[5] >

Extremely important

4.

What can people do to reduce the triggers for asthma in the air?

Adults should avoid smoking indoors when someone with asthma lives there,

and look for other sources of indoor gases (ovens, etc .).

L- Individuals should make sure all indoor surfaces are regularly cleaned or

vacuumed

.

l/Communities

should identify sources of fine particulate pollution

(diesel exhaust, etc.)

Illinois IEPA should eliminate sources of pollution that contribute to asthma .

L

~ 1JAI ~•4~ c (Yf L1ul

---

[1]

[2]

K

[4]

[5]

Not at all important

4.

What can people do to reduce the triggers for asthma in the air?

Name:

Address

:

CLEAN AIR QUESTIONNAIRE

HAROLD WASHINGTON COLLEGE

AUTUMN, 2006

We would like to ask for your help to get a better insight on how people view the severity

of what's going on in our world today . As part of that, we would like to ask a few

questions about asthma and how much you know

. We thank you for taking the time to fill

this out and would appreciate your honesty .

I .

Basic Information

Age : J'< Sex : -f Race/Ethnicity :

Per ,

.~

2.

Do you have asthma, or do you know anyone who has asthma?

[ ] Yes

[X] No

3.

How important is air pollution as being a trigger for asthma?

Extremely important

Adults should avoid smoking indoors when someone with asthma lives there,

and look for other sources of indoor gases (ovens, etc .) .

Individuals should make sure all indoor surfaces are regularly cleaned or

vacuumed.

Communities should identify sources of fine particulate pollution

(diesel exhaust, etc.)

x

Illinois IEPA should eliminate sources of pollution that contribute to asthma

.

---

Name :

Address:

CLEAN AIR QUESTIONNAIRE

HAROLD WASHINGTON COLLEGE

AUTUMN, 2006

We would like to ask for your help to get a better insight on how people view the severity

of what's going on in our world today

. As part of that, we would like to ask a few

questions about asthma and how much you know

. We thank you for taking the time to fill

this out and would appreciate your honesty .

Basic Information

Age: 2'

Sex: Race/Ethnicity : \,(-

2 .

Do you have asthma, or do you know anyone who has asthma?

VYes

[ ] No

3 .

How important is air pollution as being a trigger for asthma?

[1]

[2]

([3])

[4]

Not at all important

[5]

~`

Extremely important

4.

What can people do to reduce the triggers for asthma in the air?

Adults should avoid smoking indoors when someone with asthma lives there,

and look for other sources of indoor gases (ovens, etc

.).

v'individuals

should make sure all indoor surfaces are regularly cleaned or

vacuumed.

Communities should identify sources of fine particulate pollution

(diesel exhaust, etc.)

Illinois IEPA should eliminate sources of pollution that contribute to asthma .

f<-

V51, ., Aaj . t1~,

---

CLEAN AIR QUESTIONNAIRE

HAROLD WASHINGTON COLLEGE

AUTUMN, 2006

We would like to ask for your help to get a better insight on how people view the severity

of what's going on in our world today . As part of that, we would like to ask a few

questions about asthma and how much you know

. We thank you for taking the time to fill

this out and would appreciate your honesty .

1 .

Basic Information

Age

: f Sex

:

L

~'`

Race/Ethnicity : `,?vu lL

1~

2.

Do you have asthma, or do you know anyone who has asthma?

4`] Yes

[

]No

3.

How important is air pollution as being a trigger for asthma?

[1]

[2]

[3]

[4)

[51

Not at all important

Extremely important

4.

What can people do to reduce the triggers for asthma in the air?

Adults should avoid smoking indoors when someone with asthma lives there,

and look for other sources of indoor gases (ovens, etc .)

.

Individuals should make sure all indoor surfaces are regularly cleaned or

vacuumed.

Communities should identify sources of fine particulate pollution

(diesel exhaust, etc.)

Illinois IEPA should eliminate sources of pollution that contribute to asthma

.

IZ

Name:

v

o

V ,

,`

Address :

---

CLEAN AIR QUESTIONNAIRE

HAROLD WASHINGTON COLLEGE

AUTUMN, 2006

We would like to ask for your help to get a better insight on how people view the severity

of what's going on in our world today

. As part of that, we would like to ask a few

questions about asthma and how much you know

. We thank you for taking the time to fill

this out and would appreciate your honesty

.

Basic Information

Age:

'

,Y

Sex : ,^'I

Race/Ethnicity :

2 .

Do you have asthma, or do you know anyone who has asthma?

[ ] Yes

[-]"No

3

.

How important is air pollution as being a trigger for asthma?

[1]

[2]

[3]

[4]

;

[,5]'

Not at all important

Extremely important

4.

What can people do to reduce the triggers for asthma in the air?

v''

Adults should avoid smoking indoors when someone with asthma lives there,

and look for other sources of indoor gases (ovens, etc

.) .

t'

Individuals should make sure all indoor surfaces are regularly cleaned or

vacuumed.

Communities should identify sources of fine particulate pollution

(diesel exhaust, etc.)

Illinois IEPA should eliminate sources of pollution that contribute to asthma

.

Name:

Address: 15 C J

a

---

CLEAN AIR QUESTIONNAIRE

HAROLD WASHINGTON COLLEGE

AUTUMN, 2006

We would like to ask for your help to get a better insight on how people view the severity

of what's going on in our world today

. As part of that, we would like to ask a few

questions about asthma and how much you know

. We thank you for taking the time to fill

this out and would appreciate your honesty .

Basic Information

Age:--` Sex

: 4 _

Race/Ethnicity : !•<,,,

Address :

2 .

Do you have asthma, or do you know anyone who has asthma?

(VfYes

[l4 No

3 .

How important is air pollution as being a trigger for asthma?

[l]

[2]

[3]

[4]

[5]

Not at all important

Extremely important

4.

What can people do to reduce the triggers for asthma in the air?

U

4

Adults should avoid smoking indoors when someone with asthma lives there,

and look for other sources of indoor gases (ovens, etc

.) .

Individuals should make sure all indoor surfaces are regularly cleaned or

vacuumed.

Communities should identify sources of fine particulate pollution

(diesel exhaust, etc.)

Illinois IEPA should eliminate sources of pollution that contribute to asthma

.

Name:

---

CLEAN AIR QUESTIONNAIRE

HAROLD WASHINGTON COLLEGE

AUTUMN, 2006

We would like to ask for your help to get a better insight on how people view the severity

of what's going on in our world today

. As part of that, we would like to ask a few

questions about asthma and how much you know . We thank you for taking the time to fill

this out and would appreciate your honesty .

Basic Information

Age: , Sex: /V1 Race/Ethnicity : /+4

2 .

Do you have asthma, or do you know anyone who has asthma?

[VI Yes

[ ] No

3.

How important is air pollution as being a trigger for asthma?

[l]

[2]

[3]

([]

[5]

Not at all important

----/

Extremely important

4.

What can people do to reduce the triggers for asthma in the air?

Adults should avoid smoking indoors when someone with asthma lives there,

and look for other sources of indoor gases (ovens, etc .) .

Individuals should make sure all indoor surfaces are regularly cleaned or

vacuumed .

Communities should identify sources of fine particulate pollution

(diesel exhaust, etc .)

T

Illinois IEPA should eliminate sources of pollution that contribute to asthma .

Name:

Address :

---

CLEAN AIR QUESTIONNAIRE

HAROLD WASHINGTON COLLEGE

AUTUMN, 2006

We would like to ask for your help to get a better insight on how people view the severity

of what's going on in our world today

. As part of that, we would like to ask a few

questions about asthma and how much you know

. We thank you for taking the time to fill

this out and would appreciate your honesty

.

Basic Information

Age:

/f

/10

Sex:

Race/Ethnicity:

2.

Do you have asthma, or do you know anyone who has asthma?

[v Yes

[ ] No

3.

How important is air pollution as being a trigger for asthma?

Not at all important

6D

Extremely important

4.

What can people do to reduce the triggers for asthma in the air?

Address :

Adults should avoid smoking indoors when someone with asthma lives there,

!and look for other sources of indoor gases (ovens, etc .).

Individuals should make sure all indoor surfaces are regularly cleaned or

vacuumed

.

Communities should identify sources of fine particulate pollution

-,/Illinois exhaust, etc

.)

-~ Illinois IEPA should eliminate sources of pollution that contribute to asthma .

Name:

V

st,u

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t!i~

t / .'

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---

Name:

Address:

CLEAN AIR QUESTIONNAIRE

HAROLD WASHINGTON COLLEGE

AUTUMN, 2006

We would like to ask for your help to get a better insight on how people view the severity

of what's going on in our world today . As part of that, we would like to ask a few

questions about asthma and how much you know

. We thank you for taking the time to fill

this out and would appreciate your honesty .

1 .

Basic Information

Age:

I '1

Sex

: ~' Race/Ethnicity : ' \ W`"

2 .

Do you have asthma, or do you know anyone who has asthma?

[ ] Yes

~ ]No

3 .

How important is air pollution as being a trigger for asthma?

[1]

[2]

[3]

[4]

Not at all important

{5]

Extremely important

4.

What can people do to reduce the triggers for asthma in the air?

Adults should avoid smoking indoors when someone with asthma lives there,

and look for other sources of indoor gases (ovens, etc

.).

Individuals should make sure all indoor surfaces are regularly cleaned or

vacuumed.

Communities should identify sources of fine particulate pollution

(diesel exhaust, etc .)

Illinois IEPA should eliminate sources of pollution that contribute to asthma

.

---

CLEAN AIR QUESTIONNAIRE

HAROLD WASHINGTON COLLEGE

AUTUMN, 2006

We would like to ask for your help to get a better insight on how people view the severity

of what's going on in our world today

. As part of that, we would like to ask a few

questions about asthma and how much you know

. We thank you for taking the time to fill

this out and would appreciate your honesty .

I .

Basic Information

Age:w Sex : Race/Ethnicity :

2 .

Do you have asthma, or do you know anyone who has asthma?

N

Yes

[ ]

No

How important is air pollution as

being a trigger for asthma?

[I]

[2]

[3]

[

Not at all important

[5]

Extremely important

4.

What can people do to reduce the triggers for asthma in the air?

v' Adults should avoid smoking indoors when someone with asthma lives there,

and look for other sources of indoor gases (ovens, etc .) .

v

Individuals should make sure all indoor surfaces are regularly cleaned or

vacuumed.

Communities should identify sources of fine particulate pollution

(diesel exhaust, etc

.)

Illinois IEPA should eliminate sources of pollution that contribute to asthma

.

Name :

Address:

---

CLEAN AIR QUESTIONNAIRE

HAROLD WASHINGTON COLLEGE

AUTUMN, 2006

We would like to ask for your help to get a better insight on how people view the severity

of what's going on in our world today

. As part of that, we would like to ask a few

questions about asthma and how much you know

. We thank you for taking the time to fill

this out and would appreciate your honesty .

1 .

Basic Information

Age

: Sex:

Race/Ethnicity :

2 .

Do you have asthma, or do you know anyone who has asthma?

[:]Yes

[ ]No

3

.

How important is air pollution as being a trigger for asthma?

[1]

[2]

[3]

[4]

151

Not at all important

Extremely important

4.

What can people do to reduce the triggers for asthma in the air?

Adults should avoid smoking indoors when someone with asthma lives there,

and look for other sources of indoor gases (ovens, etc

.).

Individuals should make sure all indoor surfaces are regularly cleaned or

vacuumed.

Communities should identify sources of fine particulate pollution

(diesel exhaust, etc

.)

Illinois IEPA should eliminate sources of pollution that contribute to asthma

.

Name:

Address : kvi

\

/-\n"

---

CLEAN AIR QUESTIONNAIRE

HAROLD WASHINGTON COLLEGE

AUTUMN, 2006

We would like to ask for your help to get a better insight on how people view the severity

of what's going on in our world today . As part of that, we would like to ask a few

questions about asthma and how much you know . We thank you for taking the time to fill

this out and would appreciate your honesty .

1 .

Basic Information

Age: l I

Sex

: Race/Ethnicity

:

2 .

Do you have asthma, or do you know anyone who has asthma?

[ ] Yes

[' ] No

3 .

How important is air pollution as being a trigger for asthma?

[1]

[2]

[3]

[4]

[5]

Not at all important

Extremely important

4 .

What can people do to reduce the triggers for asthma in the air?

Adults should avoid smoking indoors when someone with asthma lives there,

and look for other sources of indoor gases (ovens, etc .).

` Individuals should make sure all indoor surfaces are regularly cleaned or

vacuumed

.

_ Communities should identify sources of fine particulate pollution

(diesel exhaust, etc .)

Illinois IEPA should eliminate sources of pollution that contribute to asthma .

Name :

I

Address: j1

---

CLEAN AIR QUESTIONNAIRE

HAROLD WASHINGTON COLLEGE

AUTUMN, 2006

We would like to ask for your help to get a better insight on how people view the severity

of what's going on in our world today

. As part of that, we would like to ask a few

questions about asthma and how much you know

. We thank you for taking the time to fill

this out and would appreciate your honesty

.

I .

Basic Information

~7

7

,7

Age:- `

c

Sex :

1-

Race/Ethnicity:

2 .

Do you have asthma, or do you know anyone who has asthma?

} Yes

[ ] No

3 .

How important is air pollution

as being a trigger for asthma?

[l]

[2]

[3]

[4]

c

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[5]

Not at all important

Extremely important

4.

What can people do to reduce the triggers for asthma in the air?

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should avoid smoking indoors when someone with asthma lives there,

x: '

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and look for

should

other

make

sources

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of

all

indoor

indoor

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cleaned or

vacuumed .

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Communities should identify sources of fine particulate pollution

(diesel exhaust, etc.)

~_ Illinois IEPA should eliminate sources of pollution that contribute to asthma

.

Name:

Address :

f (r11t ;~4

( ".

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r~~

(i7~) b 6

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---

CLEAN AIR QUESTIONNAIRE

HAROLD WASHINGTON COLLEGE

AUTUMN, 2006

We would like to ask for your help to get a better insight on how people view the severity

of what's going on in our world today

. As part of that, we would like to ask a few

questions about asthma and how much you know . We thank you for taking the time to fill

this out and would appreciate your honesty .

Basic Information

Age :

i I

Sex : 'A

2.

Do you have asthma, or do you know anyone who has asthma?

[ ] Yes

t

No

3 .

How important is air pollution

as

being a trigger for asthma?

[1]

[2]

[3]

1W

[5]

Not at all important

Extremely important

4.

What can people do to reduce the triggers for asthma in the air?

Name:

Address:

)Cn 4

Race/Ethnicity :

G Adults should avoid smoking indoors when someone with asthma lives there,

and look for other sources of indoor gases (ovens, etc

.).

Individuals should make sure all indoor surfaces are regularly cleaned or

vacuumed .

~1

Communities should identify sources of fine particulate pollution

(diesel exhaust, etc .)

Illinois IEPA should eliminate sources of pollution that contribute to asthma

.

---

Address

:

CLEAN AIR QUESTIONNAIRE

HAROLD WASHINGTON COLLEGE

AUTUMN, 2006

We would like to ask for your help to get a better insight on how people view the severity

of what's going on in our world today

. As part of that, we would like to ask a few

questions about asthma and how much you know . We thank you for taking the time to fill

this out and would appreciate your honesty.

1 .

Basic Information

Age:

t

Sex :

Race/Ethnicity:

2 .

Do you have asthma, or do you know anyone who has asthma?

[v] Yes

[ ]No

How important is air pollution as

being a trigger for asthma?

[1]

[2]

[3]

, L4]

[5]

Not at all important

Extremely important

4.

What can people do to reduce the triggers for asthma in the air?

Adults should avoid smoking indoors when someone with asthma lives there,

and look for other sources of indoor gases (ovens, etc .) .

Individuals should make sure all indoor surfaces are regularly cleaned or

V

vacuumed

.

Communities should identify sources of fine particulate pollution

Name:

\,l

(diesel exhaust, etc .)

Illinois IEPA should eliminate sources of pollution that contribute to asthma .

---

CLEAN AIR QUESTIONNAIRE

HAROLD WASHINGTON COLLEGE

AUTUMN, 2006

We would like to ask for your help to get a better insight on how people view the severity

of what's going on in our world today

. As part of that, we would like to ask a few

questions about asthma and how much you know

. We thank you for taking the time to fill

this out and would appreciate your honesty .

Basic Information

Age: 61-

Sex: kl Race/Ethnicity

: 1-~

2 .

Do you have asthma, or do you know anyone who has asthma?

[ ] Yes

[,f No

3 .

How important is air pollution as being a trigger for asthma?

[1]

[21

[31/

[4]

[5]

Not at all important

V

Extremely important

4.

What can people do to reduce the triggers for asthma in the air?

Adults should avoid smoking indoors when someone with asthma lives there,

and look for other sources of indoor gases (ovens, etc

.).

Individuals should make sure all indoor surfaces are regularly cleaned or

vacuumed .

Communities should identify sources of fine particulate pollution

(diesel exhaust, etc.)

•I

llinois IEPA should eliminate sources of pollution that contribute to asthma

.

Name:

Address:

---

CLEAN AIR QUESTIONNAIRE

HAROLD WASHINGTON COLLEGE

AUTUMN, 2006

We would like to ask for your help to get a better insight on how people view the severity

of what's going on in our world today

. As part of that, we would like to ask a few

questions about asthma and how much you know . We thank you for taking the time to fill

this out and would appreciate your honesty .

I .

Basic Information

Age:

X~

Sex : _NA

Race/Ethnicity : t 1 t z:

2.

Do you have asthma, or do you know anyone who has asthma?

[ ] Yes

[h] No

3.

How important is air pollution as being a trigger for asthma?

Not at all important

[1]

Extrem uhportant

[2]

[34

[4]

4.

What can people do to reduce the triggers for asthma in the air?

y,/Adults should avoid smoking indoors when someone with asthma lives there,

and look for other sources of indoor gases (ovens, etc .).

_ Individuals should make sure all indoor surfaces are regularly cleaned or

vacuumed .

V/

Communities should identify sources of fine particulate pollution

(diesel exhaust, etc .)

v

Illinois IEPA should eliminate sources of pollution that contribute to asthma

.

Name :

r`"An •, "&cZ,`ETrt_

Address: j'71 ' )J

i,):CS

i

---

CLEAN AIR QUESTIONNAIRE

HAROLD WASHINGTON COLLEGE

AUTUMN, 2006

We would like to ask for your help to get a better insight on how people view the severity

of what's going on in our world today

. As part of that, we would like to ask a few

questions about asthma and how much you know

. We thank you for taking the time to fill

this out and would appreciate your honesty

.

1 .

Basic Information

Age:j r,

sex: Race/Ethnicity

: ;,;;n

2.

Do you have asthma, or do you know anyone who has asthma?

[Vi Yes

[ ] No

3 .

How important is air pollution as being a trigger for asthma?

Address :

[1]

[2]

[3]

[4]

[5}

Not at all important

Extremely important

4.

What can people do to reduce the triggers for asthma in the air?

7

Adults should avoid smoking indoors when someone with asthma lives there,

and look for other sources of indoor gases (ovens, etc .).

Individuals should make sure all indoor surfaces are regularly cleaned or

Name:

i

vacuumed .

Communities should identify sources of fine particulate pollution

(diesel exhaust, etc.)

Illinois IEPA should eliminate sources of pollution that contribute to asthma

.

---

Address:

CLEAN AIR QUESTIONNAIRE

HAROLD WASHINGTON COLLEGE

AUTUMN, 2006

We would like to ask for your help to get a better insight on how people view the severity

of what's going on in our world today . As part of that, we would like to ask a few

questions about asthma and how much you know

. We thank you for taking the time to fill

this out and would appreciate your honesty

.

1 .

Basic Information

Age : -;;

\v

Sex :

Race/Ethnicity :' >IC

.

k iL

2 .

Do you have asthma, or do you know anyone who has asthma?

Yes

[ ] No

3

.

How important is air pollution as being a trigger for asthma?

[1]

[2]

[3]

[4]

Not at all important

Extrem

4.

What can people do to reduce the triggers for asthma in the air?

Name:

X

X

Adults should avoid smoking indoors when someone with asthma lives there,

and look for other sources of indoor gases (ovens, etc .).

Individuals should make sure all indoor surfaces are regularly cleaned or

vacuumed.

Communities should identify sources of fine particulate pollution

(diesel exhaust, etc.)

Illinois IEPA should eliminate sources of pollution that contribute to asthma

.

important

---

CLEAN AIR QUESTIONNAIRE

HAROLD WASHINGTON COLLEGE

AUTUMN, 2006

We would like to ask for your help to get a better insight on how people view the severity

of what's going on in our world today

. As part of that, we would like to ask a few

questions about asthma and how much you know

. We thank you for taking the time to fill

this out and would appreciate your honesty

.

I .

Basic Information

Age:

,

/- Sex:

Race/Ethnicity : 1V

2.

Do you have asthma, or do you know anyone who has asthma?

[

]Yes

r ]f

No

3 .

How important is air pollution as being a trigger for asthma?

[1]

[2]

[3]

[4]

'

[5]

Not at all important

Extremely important

4.

What can people do to reduce the triggers for asthma in the air?

Adults should avoid smoking indoors when someone with asthma lives there,

and look for other sources of indoor gases (ovens, etc

.).

Individuals should make sure all indoor surfaces are regularly cleaned or

vacuumed.

Communities should identify sources of fine particulate pollution

(diesel exhaust, etc .)

Illinois IEPA should eliminate sources of pollution that contribute to asthma

.

Name:

('

(,

if

<)G~U('~ v1

Address:

~'

'

---

CLEAN AIR QUESTIONNAIRE

HAROLD WASHINGTON COLLEGE

AUTUMN, 2006

We would like to ask for your help to get a better insight on how people view the severity

of what's going on in our world today . As part of that, we would like to ask a few

questions about asthma and how much you know

. We thank you for taking the time to fill

this out and would appreciate your honesty

.

1 .

Basic Information

Age:,- •~

Sex:

Race/Ethnicity :i 1

2.

Do you have asthma, or do you know anyone who has asthma?

[ ] Yes

[ ]No

3

.

How important is air pollution as being a trigger for asthma?

[1]

[2]

[3]

[4]'

[5]

Not at all important

Extremely important

4.

What can people do to reduce the triggers for asthma in the air?

Adults should avoid smoking indoors when someone with asthma lives there,

and look for other sources of indoor gases (ovens, etc

.).

Individuals should make sure all indoor surfaces are regularly cleaned or

vacuumed.

-Communities should identify sources of fine particulate pollution

(diesel exhaust, etc .)

Illinois IEPA should eliminate sources of pollution that contribute to asthma

.

Name:

l t

Address :

C

---

2 .

Do you have asthma, or do you know anyone who has asthma?

[ ] Yes

~, ]

No

3 .

How important is air pollution as being a trigger for asthma?

[1]

[2]

[3]

14]

[5]

Not at all important

Extremely important

4 .

What can people do to reduce the triggers for asthma in the air?

Name:

Address :

CLEAN AIR QUESTIONNAIRE

HAROLD WASHINGTON COLLEGE

AUTUMN, 2006

We would like to ask for your help to get a better insight on how people view the severity

of what's going on in our world today . As part of that, we would like to ask a few

questions about asthma and how much you know . We thank you for taking the time to fill

this out and would appreciate your honesty .

Basic Information

Age:' Sex:

Race/Ethnicity :

Adults should avoid smoking indoors when someone with asthma lives there,

and look for other sources of indoor gases (ovens, etc

.) .

Individuals should make sure all indoor surfaces are regularly cleaned or

vacuumed.

Communities should identify sources of fine particulate pollution

(diesel exhaust, etc .)

Illinois IEPA should eliminate sources of pollution that contribute to asthma

.

---

CLEAN AIR QUESTIONNAIRE

HAROLD WASHINGTON COLLEGE

AUTUMN, 2006

We would like to ask for your help to get a better insight on how people view the severity

of what's going on in our world today

. As part of that, we would like to ask a few

questions about asthma and how much you know

. We thank you for taking the time to fill

this out and would appreciate your honesty .

Basic Information

Age:

Sex :

rt

Race/Ethnicity : (

2

.

Do you have asthma, or do you know anyone who has asthma?

[ I Yes

[\j ]- No

3 .

How important is air pollution as being a trigger for asthma?

[1]

[2]

[3]

[4]

151

Not at all important

Extremely important

4.

What can people do to reduce the triggers for asthma in the air?

Adults should avoid smoking indoors when someone with asthma lives there,

and look for other sources of indoor gases (ovens, etc

.).

Individuals should make sure all indoor surfaces are regularly cleaned or

vacuumed .

~' Communities should identify sources of fine particulate pollution

(diesel exhaust, etc .)

Illinois IEPA should eliminate sources of pollution that contribute to asthma

.

Name

:

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Address:

17 I t; .

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---

CLEAN AIR QUESTIONNAIRE

HAROLD WASHINGTON COLLEGE

AUTUMN, 2006

We would like to ask for your help to get a better insight on how people view the severity

of what's going on in our world today

. As part of that, we would like to ask a few

questions about asthma and how much you know

. We thank you for taking the time to fill

this out and would appreciate your honesty .

1 .

Basic Information

Age:

2

i

Sex:

L

Race/Ethnicity:

2 .

Do you have asthma, or do you know anyone who has asthma?

[.I] Yes

[ ] No

3 .

How important is air pollution as being a trigger for asthma?

[3]

i

[4]

q5j:)

Not at all important

Extremely important

L

4.

What can people do to reduce the triggers for asthma in the air?

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Adults should avoid smoking indoors when someone with asthma lives there,

and look for other sources of indoor gases (ovens, etc .).

Individuals should make sure all indoor surfaces are regularly cleaned or

vacuumed.

Communities should identify sources of fine particulate pollution

(diesel exhaust, etc .)

Illinois IEPA should eliminate sources of pollution that contribute to asthma

.

Name

:

Address:

---

CLEAN AIR QUESTIONNAIRE

HAROLD WASHINGTON COLLEGE

AUTUMN, 2006

We would like to ask for your help to get a better insight on how people view the severity

of what's going on in our world today . As part of that, we would like to ask a few

questions about asthma and how much you know

. We thank you for taking the time to fill

this out and would appreciate your honesty .

Basic Information

Age: Sex:

__ .~

Race/Ethnicity :

2.

Do you have asthma, or do you know anyone who has asthma?

[ ] Yes

[ ] No

3.

How important is air pollution as being a trigger for asthma?

[1]

[2]

[3]

[4]

[5]

Not at all important

tremely imp ortyt t

4.

What can people do to reduce the triggers for asthma in the air?

L

Adults should avoid smoking indoors when someone with asthma lives there,

and look for other sources of indoor gases (ovens, etc

.).

Individuals should make sure all indoor surfaces are regularly cleaned or

vacuumed

.

Communities should identify sources of fine particulate pollution

;q .,(diesel exhaust, etc .)

1! Illinois IEPA should eliminate sources of pollution that contribute to asthma

.

Name: /

nf lti {

f

Address:

Z

---

CLEAN AIR QUESTIONNAIRE

HAROLD WASHINGTON COLLEGE

AUTUMN, 2006

We would like to ask for your help to get a better insight on how people view the severity

of what's going on in our world today

. As part of that, we would like to ask a few

questions about asthma and how much you know

. We thank you for taking the time to fill

this out and would appreciate your honesty

.

Basic Information

N

Age: c. j

2.

Sex:

Race/Ethnicity : f

I

~-4

Do you have asthma, or do you know anyone who has asthma?

[ ] Yes

[)'No

3.

How important is air pollution as being a trigger for asthma?

[1]

[2]

[3]

[4]

..

[5]

)

Not at all important

Ext eq~ly important

4 .

What, can people do to reduce the triggers for asthma in the air?

V Adults should avoid smoking indoors when someone with asthma lives there,

and look for other sources of indoor gases (ovens, etc

.).

Individuals should make sure all indoor surfaces are regularly cleaned or

V

vacuumed.

Communities should identify sources of fine particulate pollution

(diesel exhaust, etc .)

Illinois IEPA should eliminate sources of pollution that contribute to asthma

.

1

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Name

:

Address:

l

~

~r1~17

R,5S

---

CLEAN AIR QUESTIONNAIRE

HAROLD WASHINGTON COLLEGE

AUTUMN, 2006

We would like to ask for your help to get a better insight on how people view the severity

of what's going on in our world today

. As part of that, we would like to ask a few

questions about asthma and how much you know

. We thank you for taking the time to fill

this out and would appreciate your honesty

.

1 .

Basic Information

Age: IV

Sex : Race/Ethnicity :4`,., . -

41~ -

2 .

Do you have asthma, or do you know anyone who has asthma?

[ ] Yes

[ ]JNo

3 .

How important is air pollution as being a trigger for asthma?

[1]

[2]

[3]

[4]

' [517

Not at all important

Extremely important

Address:

5 3 7En//

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4.

What can people do to reduce the triggers for asthma in the air?

.j

Adults should avoid smoking indoors when someone with asthma lives there,

and look for other sources of indoor gases (ovens, etc

.).

Individuals should make sure all indoor surfaces are regularly cleaned or

vacuumed .

Communities should identify sources of fine particulate pollution

(diesel exhaust, etc

.)

Illinois IEPA should eliminate sources of pollution that contribute to asthma

.

Name:

Kzq, h' S, I

---

CLEAN AIR QUESTIONNAIRE

HAROLD WASHINGTON COLLEGE

AUTUMN, 2006

We would like to ask for your help to get a better insight on how people view the severity

of what's going on in our world today

. As part of that, we would like to ask a few

questions about asthma and how much you know . We thank you for taking the time to fill

this out and would appreciate your honesty .

Basic Information

Age: Sex: ~' Race/Ethnicity

:

l~

-

2.

Do you have asthma, or do you know anyone who has asthma?

[ ] Yes

D~dNo

3.

How important is air pollution as being a trigger for asthma?

[1]

[2]

[3]

[4]

Not at all important

js]

Extremely important

4 .

What can people do to reduce the triggers for asthma in the air?

j

'Adults should avoid smoking indoors when someone with asthma lives there,

and look for other sources of indoor gases (ovens, etc

.).

Individuals should make sure all indoor surfaces are regularly cleaned or

vacuumed.

Communities should identify sources of fine particulate pollution

(diesel exhaust, etc .)

Illinois IEPA should eliminate sources of pollution that contribute to asthma

.

Name:

Address

:

---

Name:

Address:

CLEAN AIR QUESTIONNAIRE

HAROLD WASHINGTON COLLEGE

AUTUMN, 2006

We would like to ask for your help to get a better insight on how people view the severity

of what's going on in our world today

. As part of that, we would like to ask a few

questions about asthma and how much you know . We thank you for taking the time to fill

this out and would appreciate your honesty .

Basic Information

Age: , Sex: `' Race/Ethnicity : I-V' ="

2 .

Do you have asthma, or do you know anyone who has asthma?

[ (] Yes

[ ] No

3.

How important is air pollution as being a trigger for asthma?

[1]

[2]

[3]

[4]

Not at all important

[k]" ,-

Extremely important

4.

What can people do to reduce the triggers for asthma in the air?

/Adults should avoid smoking indoors when someone with asthma lives there,

and look for other sources of indoor gases (ovens, etc .).

Individuals should make sure all indoor surfaces are regularly cleaned or

vacuumed.

i

Communities should identify sources of fine particulate pollution

(diesel exhaust, etc

.)

Illinois IEPA should eliminate sources of pollution that contribute to asthma

.

Vl

titi' l'

}ltx

---

CLEAN AIR QUESTIONNAIRE

HAROLD WASHINGTON COLLEGE

AUTUMN, 2006

We would like to ask for your help to get a better insight on how people view the severity

of what's going on in our world today . As part of that, we would like to ask a few

questions about asthma and how much you know

. We thank you for taking the time to fill

this out and would appreciate your honesty .

I .

Basic Information

Age

:`' %

Sex

: /~ 1

Race/Ethnicity : fj i'ii, c

r}-,~-

.1-rY1641

cfl-,+

2.

Do you have asthma, or do you know anyone who has asthma?

[ ]Yes

~~No

3 .

How important is air pollution as being a trigger for asthma?

[I]

[2]

[3]

[4]

~' [5]"/

Not at all important

Extremely important

4.

What can people do to reduce the triggers for asthma in the air?

Adults should avoid smoking indoors when someone with asthma lives there,

and look for other sources of indoor gases (ovens, etc .).

Individuals should make sure all indoor surfaces are regularly cleaned or

vacuumed .

V Communities should identify sources of fine particulate pollution

(diesel exhaust, etc.)

Illinois IEPA should eliminate sources of pollution that contribute to asthma

.

Name:

y - I,J;74--^

rvy L

<

is

Address:

r.l

v

S;

---

Age:

11

CLEAN AIR QUESTIONNAIRE

HAROLD WASHINGTON COLLEGE

AUTUMN, 2006

We would like to ask for your help to get a better insight on how people view the severity

of what's going on in our world today . As part of that, we would like to ask a few

questions about asthma and how much you know

. We thank you for taking the time to fill

this out and would appreciate your honesty .

I .

Basic Information

Sex: Race/Ethnicity :

2 .

Do you have asthma, or do you know anyone who has asthma?

[ ]Yes

[ ] No

3 .

How important is air pollution as being a trigger for asthma?

[1]

[2]

[3]

[4]

[5]

Not at all important

Extremely important

4 .

What can people do to reduce the triggers for asthma in the air?

L

Adults should avoid smoking indoors when someone with asthma lives there,

and look for other sources of indoor gases (ovens, etc .).

Individuals should make sure all indoor surfaces are regularly cleaned or

vacuumed

.

T

Communities should identify sources of fine particulate pollution

(diesel exhaust, etc.)

Illinois IEPA should eliminate sources of pollution that contribute to asthma .

Name:

Address:

---

CLEAN AIR QUESTIONNAIRE

HAROLD WASHINGTON COLLEGE

AUTUMN, 2006

We would like to ask for your help to get a better insight on how people view the severity

of what's going on in our world today

. As part of that, we would like to ask a few

questions about asthma and how much you know

. We thank you for taking the time to fill

this out and would appreciate your honesty

.

1 .

Basic Information

2 .

Age:

Sex:

Race/Ethnicity:

Do you have asthma, or do you know anyone who has asthma?

[/IYes

[ ] No

3 .

How important is air pollution as being a trigger for asthma?

[1]

[2]

[3]

[4]

L l

Not at all important

Extremely knportant

4.

What can people do to reduce the triggers for asthma in the air?

~'

Adults should avoid smoking indoors when someone with asthma lives there,

and look for other sources of indoor gases (ovens, etc

.).

Individuals should make sure all indoor surfaces are regularly cleaned or

Vacuumed.

Communities should identify sources of fine particulate pollution

/(diesel exhaust, etc .)

c/ Illinois IEPA should eliminate sources of pollution that contribute to asthma

.

1

Name:

-~ ' e

'

AE ~ - J

n)f}

~1y JJA

lr

Address :

-

L

-oLi-

I

F

---

CLEAN AIR QUESTIONNAIRE

HAROLD WASHINGTON COLLEGE

AUTUMN, 2006

We would like to ask for your help to get a better insight on how people view the severity

of what's going on in our world today . As part of that, we would like to ask a few

questions about asthma and how much you know

. We thank you for taking the time to fill

this out and would appreciate your honesty

.

1 .

Basic Information

Age :

Sex:

Race/Ethnicity :

2.

Do you have asthma, or do you know anyone who has asthma?

[ ] Yes

[

3 .

How important is air pollution as being a trigger for asthma?

[1]

[21

[3]

i[41

[5]

Not at all important

Extremely important

4.

What can people do to reduce the triggers for asthma in the air?

i Adults should avoid smoking indoors when someone with asthma lives there,

and look for other sources of indoor gases (ovens, etc .).

Individuals should make sure all indoor surfaces are regularly cleaned or

vacuumed

.

Communities should identify sources of fine particulate pollution

(diesel exhaust, etc .)

t Illinois IEPA should eliminate sources of pollution that contribute to asthma

.

Name:

Address:

---

Name:

CLEAN AIR QUESTIONNAIRE

HAROLD WASHINGTON COLLEGE

AUTUMN, 2006

We would like to ask for your help to get a better insight on how people view the severity

of what's going on in our world today

. As part of that, we would like to ask a few

questions about asthma and how much you know

. We thank you for taking the time to fill

this out and would appreciate your honesty .

1 .

Basic Information

Age:

a

I Sex: Race/Ethnicity : ~~l sit

l

2.

Do you have asthma, or do you know anyone who has asthma?

[A j Yes

[ ]No

3 .

How important is air pollution as being a trigger for asthma?

[1]

[2]

[3]

[41

[5]

Not at all important

Extremely important

4.

What can people do to reduce the triggers for asthma in the air?

Adults should avoid smoking indoors when someone with asthma lives there,

and look for other sources of indoor gases (ovens, etc .).

Individuals should make sure all indoor surfaces are regularly cleaned or

vacuumed.

Communities should identify sources of fine particulate pollution

(diesel exhaust, etc

.)

Illinois IEPA should eliminate sources of pollution that contribute to asthma

.

t {'!

(LV'

.

ItM/ R .

Address:

l y lL/

ti i1~ l

U

---

CLEAN AIR QUESTIONNAIRE

HAROLD WASHINGTON COLLEGE

AUTUMN, 2006

We would like to ask for your help to get a better insight on how people view the severity

of what's going on in our world today

. As part of that, we would like to ask a few

questions about asthma and how much you know

. We thank you for taking the time to fill

this out and would appreciate your honesty .

1 .

Basic Information

Age :

- Sex: / ; Race/Ethnicity

:

c

2.

Do you have asthma, or do you know anyone who has asthma?

Y ]

Yes

[ ]No

3 .

How important is air pollution as being a trigger for asthma?

[1]

([2] )

[3]

[4]

[5]

Not at all important

Extremely important

4.

What can people do to reduce the triggers for asthma in the air?

Adults should avoid smoking indoors when someone with asthma lives there,

and look for other sources of indoor gases (ovens, etc

.).

Individuals should make sure all indoor surfaces are regularly cleaned or

vacuumed

.

Communities should identify sources of fine particulate pollution

(diesel exhaust, etc

.)

Illinois IEPA should eliminate sources of pollution that contribute to asthma

.

Name:

Address:

---

Not at all important

CLEAN AIR QUESTIONNAIRE

HAROLD WASHINGTON COLLEGE

AUTUMN, 2006

We would like to ask for your help to get a better insight on how people view the severity

of what's going on in our world today

. As part of that, we would like to ask a few

questions about asthma and how much you know

. We thank you for taking the time to fill

this out and would appreciate your honesty .

1 .

Basic Information

Age: ,)C Sex : Race/Ethnicity : -) Ct

2 .

Do you have asthma, or do you know anyone who has asthma?

[ ] Yes

[~ No

3 .

How important is air pollution as being a trigger for asthma?

[1]

[2]

[3]

[4]

t5],

important

4 .

What can people do to reduce the triggers for asthma in the air?

Adults should avoid smoking indoors when someone with asthma lives there,

and look for other sources of indoor gases (ovens, etc .).

Individuals should make sure all indoor surfaces are regularly cleaned or

vacuumed.

Communities should identify sources of fine particulate pollution

(diesel exhaust, etc .)

Illinois IEPA should eliminate sources of pollution that contribute to asthma.

Name:

Address:

! YL ',

.

6)j j C)

---

Name:

Address :

CLEAN AIR QUESTIONNAIRE

HAROLD WASHINGTON COLLEGE

AUTUMN, 2006

We would like to ask for your help to get a better insight on how people view the severity

of what's going on in our world today

. As part of that, we would like to ask a few

questions about asthma and how much you know . We thank you for taking the time to fill

this out and would appreciate your honesty .

1 .

Basic Information

2 .

Age : Sex: I Race/Ethnicity:

Do you

have asthma, or do you know anyone who has asthma?

[,I

Yes

[ ]No

3 .

How important is air pollution as being a trigger for asthma?r.t

,

[1]

[2]

[3]

[4]

Not at all important

[5] %

ExtSmely important

4.

What can people do to reduce the triggers for asthma in the air?

Adults should avoid smoking indoors when someone with asthma lives there,

,/, and look for other sources of indoor gases (ovens, etc .).

Individuals should make sure all indoor surfaces are regularly cleaned or

vacuumed.

Communities should identify sources of fine particulate pollution

(diesel exhaust, etc .)

Illinois IEPA should eliminate sources of pollution that contribute to asthma.

C-

U

---

CLEAN AIR QUESTIONNAIRE

HAROLD WASHINGTON COLLEGE

AUTUMN, 2006

We would like to ask for your help to get a better insight on how people view the severity

of what's going on in our world today . As part of that, we would like to ask a few

questions about asthma and how much you know

. We thank you for taking the time to fill

this out and would appreciate your honesty .

1 .

Basic Information

4/

Age

:r,-Nc

A

Sex:

/7

Race/Ethnicity : n

2.

Do you have asthma, or do you know anyone who has asthma?

[ ]Yes

klyo

3 .

How important is air pollution as being a trigger for asthma?

[1]

[2]

[3]

[4]

[~5]

Extre

Not at all important

i portant

4.

What can people do to reduce the triggers for asthma in the air?

Name: l~zr ~

. ~,Ti~r rl_~

Address:

V'

Adults should avoid smoking indoors when someone with asthma lives there,

and look for other sources of indoor gases (ovens, etc .).

~' Individuals should make sure all indoor surfaces are regularly cleaned or

vacuumed.

~t

Communities should identify sources of fine particulate pollution

(diesel exhaust, etc

.)

Illinois IEPA should eliminate sources of pollution that contribute to asthma

.

---

CLEAN AIR QUESTIONNAIRE

HAROLD WASHINGTON COLLEGE

AUTUMN, 2006

We would like to ask for your help to get a better insight on how people view the severity

of what's going on in our world today. As part of that, we would like to ask a few

questions about asthma and how much you know . We thank you for taking the time to fill

this out and would appreciate your honesty

.

1 .

Basic Information

2 .

Age:sex

:

- ~ Race/Ethnicity

:

Do you have asthma, or do you know anyone who has asthma?

IYkYes

[ ]No

3.

How important is air pollution as being a trigger for asthma?

[1]

[2]

[3]

[4]

Not at all important

Extreme y important

4.

What can people do to reduce the triggers for asthma in the air?

V-Adults should avoid smoking indoors when someone with asthma lives there,

, /~d look for other sources of indoor gases (ovens, etc

.).

V Individuals should make sure all indoor surfaces are regularly cleaned or

vacuumed.

L Communities should identify sources of fine particulate pollution

diesel exhaust, etc .)

Illinois IEPA should eliminate sources of pollution that contribute to asthma .

NameAddress

:

:

i 7 X

1 j1

---

CLEAN AIR QUESTIONNAIRE

HAROLD WASHINGTON COLLEGE

AUTUMN, 2006

We would like to ask for your help to get a better insight on how people view the severity

of what's going on in our world today

. As part of that, we would like to ask a few

questions about asthma and how much you know

. We thank you for taking the time to fill

this out and would appreciate your honesty

.

1 .

Basic Information

Age:

Sex : Race/Ethnicity

: ~~

2.

Do you have asthma, or do you know anyone who has asthma?

Yes

[

]No

3.

How important is air pollution as being a trigger for asthma?

[1]

[2]

[3]

[4]

[5]

Not at all important

Extremely important

4.

What can people do to reduce the triggers for asthma in the air?

Adults should avoid smoking indoors when someone with asthma lives there,

t

Individuals

and look for

should

other

make

sources

sure

of

all

indoor

indoor

gases

surfaces

(ovens,

are

etcregularly

.) .

cleaned or

vacuumed .

Communities should identify sources of fine particulate pollution

(diesel exhaust, etc.)

Illinois IEPA should eliminate sources of pollution that contribute to asthma

.

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n

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:

wl~

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---

CLEAN AIR QUESTIONNAIRE

HAROLD WASHINGTON COLLEGE

AUTUMN, 2006

We would like to ask for your help to get a better insight on how people view the severity

of what's going on in our world today

. As part of that, we would like to ask a few

questions about asthma and how much you know

. We thank you for taking the time to fill

this out and would appreciate your honesty

.

1 .

Basic Information

Age: Sex :' - Race/Ethnicity :

F, J

2.

Do you have asthma, or do you know anyone who has asthma?

[ ] Yes

[`]-No

3 .

How important is air pollution as being a trigger for asthma?

[1]

[2]

[3]

[4]

[5]

Not at all important

Extremely important

4.

What can people do to reduce the triggers for asthma in the air?

_ Adults should avoid smoking indoors when someone with asthma lives there,

and look for other sources of indoor gases (ovens, etc .).

Individuals should make sure all indoor surfaces are regularly cleaned or

vacuumed.

Communities should identify sources of fine particulate pollution

(diesel exhaust, etc.)

Illinois IEPA should eliminate sources of pollution that contribute to asthma.

Name:

Address :

( /' >

c C;~)( f,

t

---

CLEAN AIR QUESTIONNAIRE

HAROLD WASHINGTON COLLEGE

AUTUMN, 2006

We would like to ask for your help to get a better insight on how people view the severity

of what's going on in our world today

. As part of that, we would like to ask a few

questions about asthma and how much you know

. We thank you for taking the time to fill

this out and would appreciate your honesty .

1 .

Basic Information

Age:`t1

Sex: t Race/Ethnicity

:

2.

Do you have asthma, or do you know anyone who has asthma?

[' Yes

[ ] No

3.

How important is air pollution as being a trigger for asthma?

[1]

[2]

[3]

[4]

Not at all important

Extreme y important

4.

What can people do to reduce the triggers for asthma in the air?

Adults should avoid smoking indoors when someone with asthma lives there,

and look for other sources of indoor gases (ovens, etc

.).

J

Individuals should make sure all indoor surfaces are regularly cleaned or

vacuumed.

Communities should identify sources of fine particulate pollution

(diesel exhaust, etc.)

Illinois IEPA should eliminate sources of pollution that contribute to asthma

.

Name:

Address: '

ul

C;C'is

I Z .

l1

'; I

J

---

Address:

CLEAN AIR QUESTIONNAIRE

HAROLD WASHINGTON COLLEGE

AUTUMN, 2006

We would like to ask for your help to get a better insight on how people view the severity

of what's going on in our world today

. As part of that, we would like to ask a few

questions about asthma and how much you know

. We thank you for taking the time to fill

this out and would appreciate your honesty .

1 .

2 .

3.

Basic Information

Age: 1,5

Sex:

"

~ l

Race/Ethnicity

:

rf!4C.~-

Do you have asthma, or do you know anyone who has asthma?

[ ] Yes

[,1

No

How important is air pollution as being a trigger for asthma?

[1]

[2]

[3]

[4]

Not at all important

~]

Extremel important

4.

What pan people do to reduce the triggers for asthma in the air?

i Adults should avoid smoking indoors when someone with asthma lives there,

and look for other sources of indoor gases (ovens, etc .).

Individuals should make sure all indoor surfaces are regularly cleaned or

~'

'vacuumed.

Communities should identify sources of fine particulate pollution

(diesel exhaust, etc.)

Illinois IEPA should eliminate sources of pollution that contribute to asthma.

Name :

])Hvc'o,I

.1c1

' ISSc'n

l

---

CLEAN AIR QUESTIONNAIRE

HAROLD WASHINGTON COLLEGE

AUTUMN, 2006

We would like to ask for your help to get a better insight on how people view the severity

of what's going on in our world today . As part of that, we would like to ask a few

questions about asthma and how much you know

. We thank you for taking the time to fill

this out and would appreciate your honesty

.

I .

Basic Information

Age :

\-\

Sex :

i v t

2.

Do you have asthma, or do you know anyone who has asthma?

-1-]

Yes

[ ]No

3.

How important is air pollution as being a trigger for asthma?

[1]

[2]

[3]

[4]

Not at all important

Extremely i portant

4.

What can people do to reduce the triggers for asthma in the air'?

Adults should avoid smoking indoors when someone with asthma lives there,

and look for other sources of indoor gases (ovens, etc .).

Individuals should make sure all indoor surfaces are regularly cleaned or

vacuumed.

Communities should identify sources of fine particulate pollution

(diesel exhaust, etc.)

Illinois IEPA should eliminate sources of pollution that contribute to asthma

.

Name

:

1' t~1`7~II

~C%hr~

Address:

Race/Ethnicity : l

,> lAe lL

---

CLEAN AIR QUESTIONNAIRE

HAROLD WASHINGTON COLLEGE

AUTUMN, 2006

We would like to ask for your help to get a better insight on how people view the severity

of what's going on in our world today . As part of that, we would like to ask a few

questions about asthma and how much you know

. We thank you for taking the time to fill

this out and would appreciate your honesty .

Basic Information

Age : Sex : I`

2 .

Race/Ethnicity : 1

Do you have asthma, or do you know anyone who has asthma?

[ ] Yes

[

3 .

How important is air pollution as being a trigger for asthma?

[1]

[2]

[3]

[4]

Not at all important

Extremely important

4 .

What can people do to reduce the triggers for asthma in the air?

Adults should avoid smoking indoors when someone with asthma lives there,

V

/and look for other sources of indoor gases (ovens, etc

.)

.

V

Individuals should make sure all indoor surfaces are regularly cleaned or

vacuumed.

Communities should identify sources of fine particulate pollution

(diesel exhaust, etc.)

Illinois IEPA should eliminate sources of pollution that contribute to asthma

.

NameAddress

:

:

V P";

Ll-L

~( ~~ D

hbi~2P~

l l

i ,

---

CLEAN AIR QUESTIONNAIRE

HAROLD WASHINGTON COLLEGE

AUTUMN, 2006

We would like to ask for your help to get a better insight on how people view the severity

of what's going on in our world today

. As part of that, we would like to ask a few

questions about asthma and how much you know . We thank you for taking the time to fill

this out and would appreciate your honesty .

Basic Information

Age:

2

t Sex : Race/Ethnicity:

Do you have asthma, or do you know anyone who has asthma?

[ ] Yes

[f] No

3 .

How important is air pollution as being a trigger for asthma?

[1]

[2]

[3]

[5]

Not at all important

Extremely important

4 .

What can people do to reduce the triggers for asthma in the air?

Adults should avoid smoking indoors when someone with asthma lives there,

and look for other sources of indoor gases (ovens, etc .) .

Individuals should make sure all indoor surfaces are regularly cleaned or

vacuumed.

',/

Communities should identify sources of fine particulate pollution

(diesel exhaust, etc .)

sL

Illinois IEPA should eliminate sources of pollution that contribute to asthma

.

Name:

/ PAP-7-,s

OADMwA

Address :

731 9

141,'

PBd L!_

C

o6¢-5

---

CLEAN AIR QUESTIONNAIRE

HAROLD WASHINGTON COLLEGE

AUTUMN, 2006

We would like to ask for your help to get a better insight on how people view the severity

of what's going on in our world today

. As part of that, we would like to ask a few

questions about asthma and how much you know

. We thank you for taking the time to fill

this out and would appreciate your honesty

.

Basic Information

Age : Sex:

L Race/Ethnicity :

2 .

Do you have asthma, or do you know anyone who has asthma?

[/] Yes

[ ] No

3 .

How important is air pollution as being a trigger for asthma?

Ill

[2]

[3]

[4]

1611

Not at all important

Extremely important

4.

What can people do to reduce the triggers for asthma in the air?

Adults should avoid smoking indoors when someone with asthma lives there,

and look for other sources of indoor gases (ovens, etc .) .

Individuals should make sure all indoor surfaces are regularly cleaned or

vacuumed.

Communities should identify sources of fine particulate pollution

(diesel exhaust, etc .)

Illinois IEPA should eliminate sources of pollution that contribute to asthma

.

I

s

I

Name

:

i1

Address:

7

;'( v l17

(fi _/1

Ui

---

CLEAN AIR QUESTIONNAIRE

HAROLD WASHINGTON COLLEGE

AUTUMN, 2006

We would like to ask for your help to get a better insight on how people view the severity

of what's going on in our world today

. As part of that, we would like to ask a few

questions about asthma and how much you know

. We thank you for taking the time to fill

this out and would appreciate your honesty .

Basic Information

Age:

915

Sex: M

Race/Ethnicity :VKI

C-h-+~ -

2

.

Do you have asthma, or do you know anyone who has asthma?

[ ]

Yes

I ot

3 .

How important is air pollution as being a trigger for asthma?

[1]

[2]

[3]

[4]

Not at all important

Extremely important

4.

What can people do to reduce the triggers for asthma in the air?

Adults should avoid smoking indoors when someone with asthma lives there,

and look for other sources of indoor gases (ovens, etc

.) .

1/ Individuals should make sure all indoor surfaces are regularly cleaned or

vacuumed.

,//

Communities should identify sources of fine particulate pollution

(diesel exhaust, etc .)

./

Illinois IEPA should eliminate sources of pollution that contribute to asthma

.

Name:

Address :

---

Name :

Address:

CLEAN AIR QUESTIONNAIRE

HAROLD WASHINGTON COLLEGE

AUTUMN, 2006

We would like to ask for your help to get a better insight on how people view the severity

of what's going on in our world today . As part of that, we would like to ask a few

questions about asthma and how much you know

. We thank you for taking the time to fill

this out and would appreciate your honesty .

1 .

Basic Information

Age:

-Z,

11

Sex: Race/Ethnicity :

2 .

Do you have asthma, or do you know anyone who has asthma?

[k{Yes

[ ] No

How important is air pollution as being a trigger for asthma?

[1]

[2]

[3]

[41

[5]

Not at all important

Extremely important

4.

What can people do to reduce the triggers for asthma in the air?

` Adults should avoid smoking indoors when someone with asthma lives there,

and look for other sources of indoor gases (ovens, etc .).

Individuals should make sure all indoor surfaces are regularly cleaned or

vacuumed.

Communities should identify sources of fine particulate pollution

(diesel exhaust, etc .)

_

Illinois IEPA should eliminate sources of pollution that contribute to asthma .

---

CLEAN AIR QUESTIONNAIRE

HAROLD WASHINGTON COLLEGE

AUTUMN, 2006

We would like to ask for your help to get a better insight on how people view the severity

of what's going on in our world today

. As part of that, we would like to ask a few

questions about asthma and how much you know

. We thank you for taking the time to fill

this out and would appreciate your honesty

.

Basic Information

Age : -

Sex : Race/Ethnicity

: " a

2 .

Do you have asthma, or do you know anyone who has asthma?

[ ] Yes

V]

No

3 .

How important is air pollution as being a trigger for asthma?

[1]

[2]

[3]

[4]

[dj

Not at all important

Extremely important

4.

What can people do to reduce the triggers for asthma in the air?

Adults should avoid smoking indoors when someone with asthma lives there,

and look for other sources of indoor gases (ovens, etc

.).

Individuals should make sure all indoor surfaces are regularly cleaned or

vacuumed.

_ Communities should identify sources of fine particulate pollution

(diesel exhaust, etc.)

Illinois IEPA should eliminate sources of pollution that contribute to asthma

.

Name:

Address

:

---

CLEAN AIR QUESTIONNAIRE

HAROLD WASHINGTON COLLEGE

AUTUMN, 2006

We would like to ask for your help to get a better insight on how people view the severity

of what's going on in our world today . As part of that, we would like to ask a few

questions about asthma and how much you know . We thank you for taking the time to fill

this out and would appreciate your honesty .

Basic Information

Age

:,,

r

Sex : I Race/Ethnicity :1,

y

2.

Do you have asthma, or do you know anyone who has asthma?

J

LX Yes

[ ] No

How important is air pollution as being a trigger for asthma?

[1]

[2]

[3]

[4]

J'

Not at all important

Extremely important

4.

What can people do to reduce the triggers for asthma in the air?

-\Adults should avoid smoking indoors when someone with asthma lives there,

,_ and look for other sources of indoor gases (ovens, etc

.).

X

_~ Individuals should make sure all indoor surfaces are regularly cleaned or

vacuumed.

Communities should identify sources of fine particulate pollution

(diesel exhaust, etc .)

Illinois IEPA should eliminate sources of pollution that contribute to asthma .

Name:

Address :

---

CLEAN AIR QUESTIONNAIRE

HAROLD WASHINGTON COLLEGE

AUTUMN, 2006

We would like to ask for your help to get a better insight on how people view the severity

of what's going on in our world today

. As part of that, we would like to ask a few

questions about asthma and how much you know

. We thank you for taking the time to fill

this out and would appreciate your honesty

.

1

.

Basic Information

Age: "

Sex : Race/Ethnicity

:

=- 2 . 7

2.

Do you have asthma, or do you know anyone who has asthma?

[ ]Yes

/

[ ] No

3 .

How important is air pollution as being a trigger for asthma?

[1]

[2]

[3]

[4]

`

[5]

. )

Not at all important

Extremely important

4.

What can people do to reduce the triggers for asthma in the air?

Adults should avoid smoking indoors when someone with asthma lives there,

and look for other sources of indoor gases (ovens, etc .).

Individuals should make sure all indoor surfaces are regularly cleaned or

vacuumed.

Communities should identify sources of fine particulate pollution

(diesel exhaust, etc .)

Illinois IEPA should eliminate sources of pollution that contribute to asthma

.

((

Name:

t/ b

/1-(" ('" -

2_t, ,

Address:

---

CLEAN AIR QUESTIONNAIRE

HAROLD WASHINGTON COLLEGE

AUTUMN, 2006

We would like to ask for your help to get a better insight on how people view the severity

of what's going on in our world today

. As part of that, we would like to ask a few

questions about asthma and how much you know . We thank you for taking the time to fill

this out and would appreciate your honesty .

I .

Basic Information

Age:

'i

,

/

Sex: ),.

.j

2.

Race/Ethnicity :

Do you have asthma, or do you know anyone who has asthma?

[Yes

[ ] No

3 .

How important is air pollution as being a trigger for asthma?

[1]

[2]

[3]

[4]

[5

Not at all important

Extreme y important

4.

What can people do to reduce the triggers for asthma in the air?

Adults should avoid smoking indoors when someone with asthma lives there,

and look for other sources of indoor gases (ovens, etc .).

Individuals should make sure all indoor surfaces are regularly cleaned or

vacuumed

.

Communities should identify sources of fine particulate pollution

(diesel exhaust, etc.)

N Illinois IEPA should eliminate sources of pollution that contribute to asthma .

Name:

Address :

K

1,-'e

4 of

---

CLEAN AIR QUESTIONNAIRE

HAROLD WASHINGTON COLLEGE

AUTUMN, 2006

We would like to ask for your help to get a better insight on how people view the severity

of what's going on in our world today . As part of that, we would like to ask a few

questions about asthma and how much you know . We thank you for taking the time to fill

this out and would appreciate your honesty

.

I .

Basic Information

Age:

I Race/Ethnicity

:L--, * ~7

2.

Do you have asthma, or do you know anyone who has asthma?

[ ] Yes

3.

How important is air pollution as being a trigger for asthma?

[1]

[2]

[3]

Not at all important

[4]

Extre

important

4.

What can people do to reduce the triggers for asthma in the air?

Adults should avoid smoking indoors when someone with asthma lives there,

and look for other sources of indoor gases (ovens, etc .) .

'Individuals should make sure all indoor surfaces are regularly cleaned or

vacuumed

.

Communities should identify sources of fine particulate pollution

'(diesel exhaust, etc.)

Illinois IEPA should eliminate sources of pollution that contribute to asthma .

Name:

Address :

---

CLEAN AIR QUESTIONNAIRE

HAROLD WASHINGTON COLLEGE

AUTUMN, 2006

We would like to ask for your help to get a better insight on how people view the severity

of what's going on in our world today . As part of that, we would like to ask a few

questions about asthma and how much you know

. We thank you for taking the time to fill

this out and would appreciate your honesty

.

1 .

Basic Information

Age:

w

Sex :

/ 7

Race/Ethnicity : A

. /~ J

2 .

Do you have asthma, or do you know anyone who has asthma?

[ ] Yes

['-A0

3

.

How important is air pollution as being a trigger for asthma?

[1]

[2]

[3]

[4]

Not at all important

~ [~5

Extreifety important

4.

What can people do to reduce the triggers for asthma in the air?

l Adults should avoid smoking indoors when someone with asthma lives there,

and look for other sources of indoor gases (ovens, etc .).

Individuals should make sure all indoor surfaces are regularly cleaned or

vacuumed.

Communities should identify sources of fine particulate pollution

(diesel exhaust, etc .)

Illinois IEPA should eliminate sources of pollution that contribute to asthma .

Name:

Address

:

---

CLEAN AIR QUESTIONNAIRE

HAROLD WASHINGTON COLLEGE

AUTUMN, 2006

We would like to ask for your help to get a better insight on how people view the severity

of what's going on in our world today

. As part of that, we would like to ask a few

questions about asthma and how much you know . We thank you for taking the time to fill

this out and would appreciate your honesty .

1 .

Basic Information

Age :

11

Sex :'f" Race/Ethnicity

:

2 .

Do you have asthma, or do you know anyone who has asthma?

[ ]Yes

4~

No

How important is air pollution as being a trigger for asthma?

[1]

[2]

[3]

Not at all important

4 .

What can people do to reduce the triggers for asthma in the air?

Adults should avoid smoking indoors when someone with asthma lives there,

and look for other sources of indoor gases (ovens, etc .).

Individuals should make sure all indoor surfaces are regularly cleaned or

V Communities

vacuumed.

should identify sources of fine particulate pollution

(diesel exhaust, etc .)

Illinois IEPA should eliminate sources of pollution that contribute to asthma

.

Name :

9Ji1ey7t4on-

Address:

1(217 W, cayw1a,

N-c T,TL1l0rnoab

yl

Extremely important

---

2.

3.

Name:

Address :

CLEAN AIR QUESTIONNAIRE

HAROLD WASHINGTON COLLEGE

AUTUMN, 2006

We would like to ask for your help to get a better insight on how people view the severity

of what's going on in our world today . As part of that, we would like to ask a few

questions about asthma and how much you know

. We thank you for taking the time to fill

this out and would appreciate your honesty .

l .

Basic Information

Age : j Sex: Y

Race/Ethnicity:

I

1

Do you have asthma, or do you know anyone who has asthma?

L.fYes

l

[ ] No

How important is air pollution as being a trigger for asthma?

A!

i

[I]

[2]

[3]

Not at all important

[4]

Extt ely important

4.

What can people do to reduce the triggers for asthma in the air?

-

Adults should avoid smoking indoors when someone with asthma lives there,

and look for other sources of indoor gases (ovens, etc .).

Individuals should make sure all indoor surfaces are regularly cleaned or

vacuumed.

Communities should identify sources of fine particulate pollution

(diesel exhaust, etc.)

Illinois IEPA should eliminate sources of pollution that contribute to asthma .

---

CLEAN AIR QUESTIONNAIRE

HAROLD WASHINGTON COLLEGE

AUTUMN, 2006

We would like to ask for your help to get a better insight on how people view the severity

of what's going on in our world today . As part of that, we would like to ask a few

questions about asthma and how much you know

. We thank you for taking the time to fill

this out and would appreciate your honesty

.

1 .

Basic Information

Age: - Sex:

Race/Ethnicity : j-Al`\ Cr,-in /'t

-111,1~ 0,'

G.4

2.

Do you have asthma, or do you know anyone who has asthma?

[ ] Yes

[\1No

3 .

How important is air pollution as being a trigger for asthma?

[1]

[2]

[3]

[4]

Not at all important

N

Extremely important

4.

What can people do to reduce the triggers for asthma in the air?

Adults should avoid smoking indoors when someone with asthma lives there,

and look for other sources of indoor gases (ovens, etc .).

Individuals should make sure all indoor surfaces are regularly cleaned or

vacuumed .

Communities should identify sources of fine particulate pollution

(diesel exhaust, etc .)

Illinois IEPA should eliminate sources of pollution that contribute to asthma

.

Name:

h-wZ °

-t%

Address: