NC Residents - Complete the survey and enter your name and address
to receive a free radon testing kit.
How did you hear about the free radon test kits?
What year was your home built?
Does your home have a...
(Check all that apply)		 Basement
Crawl Space
Slab Foundation
Don't Know
Type of water supplied to home? Private Well
Community Well
City/County Water
Don't Know
Are there children living in the home on a permanent basis? Yes
No
Have you tested your home for radon before? Yes
No
If yes, when?
Are there any Smokers in the home? Yes
No
Recipient Information
Full name:
Street:
City:
State:   Zip:
Email:

By submitting this form, you acknowledge you may be contacted by the North Carolina Radon Program about the use of your radon test kit. You will not receive marketing information and your information will not be released to 3rd parties. If you are contacted, it will only relate to the use of the radon test kit that was provided to you by the NC Radon Program.