2. Name*
3. What Town or City do you live in?*
   -- Select One --City of AuburnTown of MentzTown of Montezuma
5. Address
7. City
8. State
9. Zip Code
11. Phone Number*
12. Do you rent or own your residence?*

    1. Rent
    2. Own
14. Age(s) of persons in the residence*

    1. 0 - 6 years old
    2. 7 - 17 years old
    3. 18 - 50 years old
    4. 51+ years old

    Please select all that apply.

16. Does anyone in the residence have asthma?

    1. Yes
    2. No
17. Does anyone in the residence smoke?

    1. Yes
    2. No
19. Is anyone in the residence currently pregnant or planning to become pregnant?

    1. Yes
    2. No
21. Do you have functioning smoke detectors?

    1. Yes
    2. No
22. Do you have functioning carbon monoxide detectors?

    1. Yes
    2. No
24. What is the primary concern in your living environment?*
    -- Select One --Indoor Air QualityLead HazardsAsthma and Allergy TriggersPest ControlFire and Carbon Monoxide SafetyResidential InjuriesOther

    What issues would you like the HNP to address? Select all that apply.

26. What OTHER concerns do you have?
28. How did you hear about the Healthy Neighborhoods Program?*

30. Thank you for filling out this form. A staff member from the Cayuga County Healthy Neighborhoods Program (HNP) will be contacting you soon to setup your no-cost home assessment.

Leave This Blank:


32. 1. Receive an email copy of this form.
33. Email address

    This field is not part of the form submission.

34. Submit

* indicates a required field