Your voluntary participation will assist scientists in designing additional research studies. It will also help us convince public policy makers to put more resources into eliminating this serious, but preventable public health risk.

 

Name:

Address:

City:

State:

Zip:

Phone:

E-mail:

Oncologist:

Date Diagnosed:

Age:

Ever Smoked?:

Years Smoked:

Radon Test Done?:

Radon Test Result:

pCi/l

 

Want Free Test?:

 

 

Test kit will be mailed to above address.  Allow 3 to 4 weeks for delivery.