Survey Of The Housing Needs Of The Chemically Injured

If you need low-toxicity housing, please take the time to fill out our housing survey. Also, if you know of others who need it, please send them a link to the survey or pass the word along to them. There is both an on-line form and a printable pdf form that can be mailed to us. Do which ever one best suits your needs. If you have questions about the Housing Survey, we encourage you to check out our Frequently Asked Questions (FAQ) page. Click here to go to the FAQ page.

Purpose of the Housing Survey

To evaluate the need for specialized, low-toxicity housing in the chemically injured community.

On-Line Version of the Survey

Below is the on-line survey. Fill out the form, verify you are not a robot, and click "Submit".

On-Line Housing Survey

Medical Diagnosis - Check as many as apply
















Does your current home meet your needs?




Due to your need for a low-toxicity home, are you currently homeless?



How urgent is it for you to move into a low-toxicity home?




Do you have mobility problems that need to be accommodated?



If you checked "Yes", check all that apply.







Would you be interested in buying or renting a low-toxicity home?




If you are interested in buying, would you be willing to rent one of the rooms to another person in need of a low-toxicity home?




If you are interested in renting, what type of low-toxicity home would you be interested in renting? Check as many as apply.






Would other family members or friends be living with you?




If you checked "Yes", would these family members or friends be willing to live a low-toxicity lifestyle, such as no scent and no smoking?




Would you benefit from living in a low-toxicity village, in which all the buildings are safe, low-toxicity buildings?




If you need to move to a low-toxicity home, how far are you willing or able to move? Check as many as apply.






Thank you for taking the time and energy to contribute to this survey. We deeply appreciate it.

Review your responses. When you are satisfied, verify you are not a robot and click "Submit".

 

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