Use this form to submit your testimony in support of the Fresh Air Deal.

Chemical Impact Testimony Form

In support of the Fresh Air Deal

Preamble
The Fresh Air Deal campaigners would like to give you the opportunity to share your story of how your health may have been impacted by chemicals in the environment. Some environmental sources of atmospheric chemical pollution are motor vehicle exhaust, nail salons, hair salons, tanning rooms, the Myers makeup and cosmetic department, perfumes, deodorants, cleaning products, carpets, paints and surface coatings, artists paints, sharpies, white board markers, vinyl in new vehicles, plastic packaging, – the list is almost endless.

Instructions
Please use the following questions as prompts to help you write your testimony.

Confidentiality
Please note that your name and address shall remain confidential unless you give permission otherwise.

Required fields are marked with an *

* First Name * Last Name * Email Address (Just the City and Country)

1. As an introduction to your testimony please give a short description of yourself as in –  gender, age, lifestyle, diet, and any health issues.

2. What types of chemicals do you feel have a negative impact upon your health?

3. Do you have any health issues which could make you more vulnerable to chemical pollution?

4. Please give some specific examples where you have been exposed to chemical pollution. Describe your symptoms and how you try and handle the situation.

5. Have you made efforts to open a discussion with the people responsible for the chemical pollution and if so what was the response?

6. May we have permission to quote your name?

no yes

7.May we have permission to quote your occupation?

no yes

8. May we have permission to quote your town and country?

no yes

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