100 Radon Test Kit Challenge

100 Radon Test Kit Challenge - Start Survey
Detector Serial Number: *
Second Detector Serial Number: (only if you received a DUPLICATE test)
Date Detector Placed *

Day Month Year
Name *

First Name Last Name
Email *
example@example.com

Radon Test Building Information *

Civic Number and Street Address of Building Tested for Radon

City of Building Tested for Radon	Province of Building Tested for Radon
Postal Code of Building Tested for Radon	Country

Radon Test Building Information Province
Which Community Awareness Project/Evening did you participate in? *
Mailing Address Same as Building Address

Yes No

Mailing Address *

Street Address

City	Province
Postal Code	Country

Mailing Address Province
Would you be interested in receiving FUTURE information from Take Action on Radon or your host community about radon? You can unsubscribe anytime.

Yes No
Please help us by answering some additional questions about your home which will be used for future research purposes. If you will provide some more details about your home, click 'YES', if not, click 'NO' and 'Submit'.

YES NO
Number of Occupants
Under 10 Years Old
Between 10 and 18 Years Old
Between 19 and 30 Years Old
Between 31 and 55 Years Old
Over 55 Years Old
Do you own or rent the building?

Own Rent
Type of Building

Single Detached Home Semi-Attached (Your home shares a wall - i.e. townhouse or duplex) Condo/apartment on ground-floor or basement Condo/apartment on second floor or above Mobile home (on the ground or on a foundation and/or with well-sealed skirting) Mobile home (raised, not in contact with the ground, or with loose skirting) Other
Please Specify
Types of openings in the lowest floor of the house or basement (check all that apply) - remove

Floor Drain Sump Cracks in Foundation Furnace Condensate/Air Conditioner Drain Walk-out basement (a full-size door that opens to the outdoors from your basement) N/A
In what year was your home originally built?

1930s or earlier 1940 through 1960 1960-1970 1970-1980 1980-1995 1996-2000 2000-2010 2011 2012 2013 2014 2015 and Newer Unknown
Are you aware of any renovations that have been carried out on the home? (click all that apply)

New windows Attic insulation Finished basement Sealing around or replacing an exterior door Improving the sealing and caulking around doors or other cracks No known renovations
Describe the renovations or energy efficiency measures, including the year completed and include any not mentioned above.
Are you aware of any energy efficiency improvements made to the home (replacing windows, improving attic insulation, improving the sealing and caulking around doors and/or cracks?

Yes No
Describe the Energy Efficient Methods
Please specify your main heating system is used in your home.

Furnace (Forced Air) Boiler (Radiators) Electric Baseboards Heat Pump Wood Fireplace Wood Stove / Pellet Stove Gas Fireplace Unknown Other
Please Specify
Is your house supplied by private well water?

Yes No Not sure
Should be Empty:

100 Radon Test Kit Challenge - Start Survey