Survey - Home Oxygen Survey (ALA)

Home Oxygen Survey (ALA)

Question - Not Required - 1. Please select the type of oxygen equipment that you use. Select all that apply.

	stationary concentrator
	standard gas cylinders
	liquid oxygen
	portable oxygen concentrator
	Other (please specify)

Question - Not Required - Other:

Question - Not Required - 2. Has the type of oxygen equipment you use changed?

Yes

No

I don't know

Question - Not Required - 3. What problems (if any) have you experienced regarding your supplemental oxygen? Select all that apply.

	Bills not explained
	Can't change companies
	Can't mix systems
	Company does not respond to calls
	Delivery problems
	Equipment not working
	Incorrect or delayed physician orders
	Lack of high flow portable systems
	Lack of portable systems I can physically manage
	Need or used to use liquid and can't get it
	Not enough portable oxygen provided so I can work
	Not enough tanks for activity outside home
	Travel oxygen problems
	Other
	No problems

Question - Not Required - 4. Please tell us more about the problems you have experienced accessing your oxygen. It is important to understand what you have been told and who told you, what actions were taken by the company and the reasons they gave and anything else you think would be helpful to better understand the extent of the problems people in the community are facing and why they are occurring.

Question - Not Required - First Name:

Question - Not Required - Last Name:

Question - Not Required - City:

Question - Not Required - State:

Question - Not Required - Zip Code:

Question - Not Required - Phone Number:

Email Address:


	Email:
	Yes, I would like to receive e-mail from the American Lung Association

Question - Not Required - Email Interests

Email Newsletters > National Newsletters -

Question - Not Required - URL Paramater