Questions neither National Grid nor the Government Will Be Asking You
(This survey may also be printed, filled out and sent to:)
Worcester Opts Out
4 Castle St.  #2
Worcester, MA.  01610-6405

(In addition to yourself, please ask any affected person you know – family, friends, neighbors, co-workers - to complete a separate survey.  Adults should fill out survey for children.)

My age:

* In the last 18 months have you been having any ongoing symptoms that began suddenly?
* Has there been a "smart" meter installed at your home?
If Yes, approximately how many feet is the ‘smart’ meter -
- from your bed?

- from the family room or place you spend significant time in the home (out of bed)?

* Does your school or workplace have a smart electric meter?
Please check all symptoms that apply:
Disease Onset, Recurrence or Exacerbation of:  (Please check any of these that apply)
Other? (Please specify)

I know I have had a 'Smart" Meter installed. (Please complete ONLY IF YOU HAVE a 'Smart' Meter installed.)
AFTER INSTALLATION:  (Please check any that apply)
Feel free to expound on any safety issue(s):
Please check those items that apply to you.
Please comment on any of the above SM related issue(s):
Approximate date of installation:
‘Smart’ Meter FCC ID#1:
‘Smart’ Meter FCC ID#2:

Overall RF/EMF exposure:  (Enter # hrs/wk you use wireless devices):
Cellular phone (both work + home)
Cordless phone (both work + home)
Wireless computer Network (WiFi)
Baby monitor - What brand?
RC (Remote Controlled) planes, etc
Other wireless (speakers, etc.)
If any neighbors have Smart Meters please enter # of neighbors or meters:
Occupational Exposure: (Please check any applicable)
Bodily Vulnerability Factors for RF/EMF exposure: (please check all applicable)


How did you learn about Worcester Opts Out and/or this survey?  (Please check all applicable)
< If so, be sure to provide contact info below >

Confidentiality Statement & Statement of Purpose

This survey is being conducted by Worcester Opts Out for independent research purposes. Answers to these questions and all personal information are completely confidential. Your answers will become part of a secure database and used only by Worcester Opts Out for our research. They will be statistically analyzed and will not be individually reported. If you give us your email, you will receive exactly one email acknowledging your submission of this survey, unless you indicate that you would like additional information and/or would like to help WOO in any way.

Worcester Opts Out is dedicated to providing accurate information about smart meters and any health effects they may be triggering. Your participation will help us achieve that goal.

CONTACT INFO:  (entirely optional: If you want to remain anonymous you can provide initials or a "handle" name. This will let us plot general trends in symptoms or parts of the city most affected, etc. Thank you.)