EPA HOTLINE

NYC 9/11 Public Portal Document

DRAFT HOTLINE QUESTIONNAIRE (& POST-SURVEY FIELD INFO)

QUESTIONNAIRE:

First Name; Last Name: Street Address: Apartment Number: Cross Street #1: Cross street #2: Telephone, daytime: Telephone, evening: email:

Number of rooms: Central air conditioning: Unit air conditioning (# units): Carpets: Describe the dust situation when you first entered your apartment: Light: Write in it: Measurable depth (estimate): Was your apartment first cleaned by; Certified asbestos contractor (name): Approximate date: Non-certified contractor: Approximate date: Housekeeper: Approximate date: Occupant: Approximate date: Was your apartment tested: Approximate date: Do you know the results: Were building common areas cleaned:

Do you want; Your apartment professionally cleaned and tested (after cleaning): (This will take 2-3 days and will require you or your representative to be present) Your apartment tested without cleaning: (If - and only if - asbestos is found during testing, you may still ask that your apartment be professionally cleaned.) A voucher for a HEP A vacuum: (You may receive a HEP A vacuum even if you have your apartment professionally cleaned) NB: Is this correct?

Post-Interview fields:

Cleanup scheduled (date): Entry notes:

NYC-WTC_000143741