| Section | Question Subject |
| Demographic characteristics | Name and surname |
| Gender | |
| Age | |
| State | |
| City | |
| Socioeconomic conditions | |
| Local environmental issues | Identification of environmental problems |
| Ranking of environmental problems | |
| Local air pollution | Perception on Air quality condition |
| Emission sources | |
| Air pollutants | |
| Magnitude of the impacts | |
| Impacts description | |
| Health related impacts perceived | |
| Characteristics of the affected population |