Draft WTC Cleaning Hotline Questionnaire Form, May 2002

NYC 9/11 Public Portal Document

DRAFT HOTLINE QUESTIONNAIRE («& POST-SURVEY FIELD INFO)

QUESTIONNAIRE:

First Name: Last Name: Street Address &AKA’s, if known : Apartment Number: Cross Street#!: Cross street #2: Telephone, -daytime: Telephone, evening: email: Fax:

Number of rooms: Central air conditioning: Unit air conditioning (number of units and location): Carpets: (number and location) Describe the dust situation when you first entered your apartment: Light: Write in it: Measurable depth (estimate): Color:

Was your apartment first cleaned by Building Owners/Managers using:

1. Certified asbestos contractor (name): Approximate date: 2. Non-certified contractor: Approximate date: 3. A certified/non-certified contractor Approxiamte date hired by resident of dwelling unit. 4. Housekeeper: Approximate date: 5. Occupant: Approximate date:

Was your apartment tested prior to and/or after cleaning: Approximate date: Do you know the results: Were building common areas cleaned:

Do you want: Your apartment professionally cleaned and tested for air quality (after cleaning): (This will take 2-3 days and will require you or your representative to be present) Your apartment tested for air quality without cleaning: (If - and only if - asbestos is found during testing, you may still ask that your apartment be professionally cleaned.)

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