Minneapolis health department asthma program enrollment

Minneapolis health department

asthma program enrollment

Date*

Program eligibility

Do you live in Minneapolis?*

Yes

Have you been diagnosed with asthma?*

Yes

Has your child been diagnosed with asthma?*

Yes

Is your child under 21 years old?*

Yes

How did you hear about our program?

Tennessen notice

Before we begin, we want to let you know that we are going to ask questions to help prepare our visit with you. The information we'll be asking for is used to figure out what your child’s needs are for asthma equipment that will be brought to you.

This form will ask you about how well your child’s asthma is under control and if their asthma symptoms have changed recently.
This form will ask some questions about your home so that we know what free equipment to bring.
This form will also ask you for your address and contact information. This information is not legally required, but it is necessary for the program to serve you. This information will stay secured in our computer system and only be used in connection with this program by program staff. You may begin filling out the form.

Contact information

If you are eligible for the program, the response space will show below. If not, please continue to submit the survey, as you may be eligible for other opportunities.

Name (first & last)*

Address*

Phone Number*

Phone

Email*

How many individuals in the house have asthma?*

Select or enter value

Children's Name(s) & Age(s)

Uncontrolled asthma

If you are eligible for the program, the response space will show below. If not, please continue to submit the survey, as you may be eligible for other opportunities.

Has your child been admitted into the emergency department in the last 12 months?

Yes

Were they hospitalized in the last 12 months, due to their asthma?

Yes

Has your child missed school in the last 12 months, due to their asthma symptoms?

Yes

Would you say that your child's asthma is under control, or would you say that they are experiencing asthma symptoms that interfere with them doing normal activities?

Select or enter value

Does your child use a rescue inhaler more than twice a week?

Yes

Indoor air-related triggers

If you are eligible for the program, the response space will show below. If not, please continue to submit the survey, as you may be eligible for other opportunities.

Have you seen any evidence of pests, like mice or cockroaches in your house?

Select or enter value

Have you seen any evidence of mold in your home or problems with water leaks?

Select or enter value

Do you rent or own your home?

Rent

Own

Asthma equipment needs

If you are eligible for the program, the response space will show below. If not, please continue to submit the survey, as you may be eligible for other opportunities.

What size mattress does your child use?

If you have more than one child, please specify the quantity needed.

Twin

Full

Queen

King

Does your child ever sleep in another bed?

Yes

If yes, then we will want to also provide a bedding encasement for your mattress as well. What size mattress do you use?

Twin

Full

Queen

King

Do you have carpet and a good working vacuum?

We are able to provide an allergen vacuum, if desired.

Yes

Follow-up survey

If you are eligible for the program, the response space will show below. If not, please continue to submit the survey, as you may be eligible for other opportunities.

We would like to understand if these products have helped your child's asthma by contacting you a few months after the home visit. Would that be okay?

Yes

Next steps

A City of Minneapolis staff member will reach out to schedule an appointment. During the appointment they will bring any asthma related equipment to you.

Please let us know if you have any questions or comments at vu.tran@minneapolismn.gov. Thanks!

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