Consent Form - Home-owner/Primary place of residence

Project Title

Climate Attribution of Wildfire Smoke Impacts on Priority Population Health in Southeast Asia and Australia (CANBREATHE)

Information Form

Please read the information form provided below before filling the consent form.

CANBREATHE Home-owner Information Form

Consent Statement

I have read and understood the information about the research. I am not aware of any condition that would prevent my participation, and I agree to participate in this project. I have had the opportunity to ask questions about my participation in the research. All the questions I have asked, have been answered to my satisfaction.

*

Please indicate whether you agree to participate in each of the following parts of the research (please indicate which parts you agree to by ticking the relevant box):

Agree to install air quality sensors and collect environmental data from my home.Agree to install and use a DIY air purifier during the haze season (if chosen).Agree to the collection of detailed manual records on home structure and occupancy.Agree to participate in semi-structured interviews.Agree to be photographed or video recorded.Agree to the information being used in future research.

Name *

Residential Address *

Street address *Street address line 2

City *

State *

Postcode *

Mobile Number *

Signature *

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Date *

A summary of the research report can be forwarded to you when published. If you would like to receive a copy of the report, please include your mailing (or email) address below.

Mailing Address

Email Address