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2. Your Name*
3. Your Address*
5. Your Telephone Number
6. Location of Incident / Observation, if Different
8. Date and Time of Incident/Observation*
   Date and Time of Incident/Observation

   Date and Time of Incident/Observation
9. Duration of Event
   Hours/Minutes
11. Problem

    1. Sound - Whooshing
    2. Sound - Thumping
    3. Sound - Jet Engine
    4. Light Flicker

    1. Pressure Change
    2. Visual
    3. Other
12. Please Describe
14. Intensity of Observed Effects

    1. 1 - No Change
    2. 2
    3. 3
    4. 4
    5. 5
    6. 6
    7. 7
    8. 8
    9. 9
    10. 10 - Unable to Perform Normal Activities

    Describe intensity of observed effects on a scale of 1 to 10 with 1 being no change to 5 being voices must be raised in normal conversation to 10; unable to perform normal activities at the location.
16. Location Effects Observed - Inside a Dwelling

    1. North Interior
    2. South Interior
    3. East Interior

    1. West Interior
    2. Windows Open
    3. Windows Closed

    1. Basement
    2. 1st Floor
    3. 2nd Floor

    1. 3rd Floor
    2. All Interior Locations
18. Outdoors - Location on the Property

    1. North Quadrant

    1. South Quadrant

    1. East Quadrant

    1. West Quadrant
20. Impact of the Observed Effect on You

    1. Sleep Disturbance
    2. Ability to Concentrate Affected

    1. Anxiety

    1. Loss of Appetite

    1. Headaches
22. Perceived Source(s)*

    1. Wind 1
    2. Wind 2

    1. Webb/Notus

    1. Woods Hole Research Associates - Woods Hole Road

    1. Other
24. Additional Comments
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27. Email address

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