Health Research Survey — Short Version

A significant number of people in Michigan and across the U.S. are reporting changes in their health.

This short survey is designed to identify what health changes are taking place (new or worsening health problems) and how widespread they are. Some of the most frequently reported problems are difficulty sleeping, ringing in the ears, headaches, and heart palpitations. We are investigating whether any health changes are correlated with the installation by your utility company of smart meters, a new type of electric meter. Many people report health changes after installation, others do not.

Please fill out this survey whether or not you are experiencing health changes. The survey takes about 7 minutes. A more comprehensive survey will be available in the near future, which will contain much more detailed questions.

This survey is being conducted by the Smart Meter Education Network (SMEN) for nonprofit research purposes. More information on confidentiality, privacy, and the SMEN can be found by clicking here.

The Smart Meter Education Network is dedicated to providing accurate information about smart meters and their health effects, if any. Your participation will help us achieve that goal. Thank you for participating.

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Background (required)

You will know if you have a smart meter because it will have blue on its face and/or a digital read-out. Show me what they look like.

My city and zip are:
My residence has a smart electric meter.	Yes No Unsure Not Applicable
If known, month/year smart meter was installed.
My workplace has a smart electric meter.	Yes No Unsure Not Applicable
I had heard of smart meters (advanced meters, AMI meters) before this survey.	Yes No Unsure
I was aware before this survey that a smart meter had been installed on my residence.	Yes No Unsure Not Applicable

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Health Changes

Have you experienced . . . .

IMPORTANT: If you know when a smart meter was installed on your home or workplace (or in your city), use this date as starting date for health changes.

Sleep problems (insomnia, difficulty falling asleep, waking at night, inability to stay asleep)	Yes No Unsure
Ear problems: ringing (tinnitus), pain, hearing a constant sound	Yes No Unsure
Difficulty focusing, concentrating, or remembering	Yes No Unsure
Feeling anxious, jittery, wired, irritable, agitated	Yes No Unsure
Heart palpitations, arrhythmia, chest pain, other heart problems	Yes No Unsure
Headaches or migraines	Yes No Unsure
Nausea	Yes No Unsure
Pressure, pain, buzzing, or clamping in head or body; feeling that something is shooting through head or body	Yes No Unsure
TMJ problems; clenching teeth	Yes No Unsure
Fatigue	Yes No Unsure
Changes in blood pressure	Yes No Unsure
Changes in diabetes, thyroid, or other endocrine systems	Yes No Unsure
Difficulty breathing, shortness of breath	Yes No Unsure
Sinus problems, nose bleeds	Yes No Unsure
Sensitivity to electrical devices (e.g., wireless, dimmer switches, halogens, CFLs, computer)	Yes No Unsure
Children: hyperactivity or changes in behavior	Yes No Unsure
Other (please list) (e.g., eye pain or dryness, rashes, facial flushing, muscle weakness, depression, seizures, flu-like symptoms, dizziness, balance problems, recurrence or exacerbation of cancer)

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Contact Information

In order to verify that this survey was submitted by you and/or to clear up any ambiguous answers, we need at least one way to contact you: an email, a phone number, or a street address. Your contact information will be used for these purposes only and is entirely confidential. Not providing contact information will also limit the uses to which we can put the data you submit (because we can’t verify that you submitted it), so we encourage you to provide at least one form of contact.

First Name.... (required)
Last Name
Email
Street Number
Street Name
City.... (required for demographics)
County
State.... (required for demographics)
Zip Code.... (required for demographics)
Age.... (required for demographics)
Phone #

Please Choose One Flyer at Home Flyer at Store Health Care Practitioner Facebook S.M.E.N. Website Email From S.M.E.N. Email From Friend How did you hear about this survey?

Additional Comments:

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I want to receive updates regarding smart meters.
I would like a copy of the survey results once they are completed.
I would like to offer help to the group, so please contact me.

If the above are selected, be sure to provide your email address as a contact method.

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Confidentiality Statement & Statement of Purpose
This survey is being conducted by the Smart Meter Education Network for nonprofit research purposes. Your answers to these questions and your personal information is completely confidential. Your answers will become part of a secure database. They will be used in statistical analysis 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.

The Smart Meter Education Network is dedicated to providing accurate information about smart meters and their health effects, if any. Your participation will help us achieve that goal.

Thank you for participating in this important research.