Indoor Air Quality Complaint

Indoor Air Quality Occupant Questionnaire

Occupant Information Occupant Name: Building Name & Room Number: Work Location: Date: Symptoms What is your chief complaint(s)?

What symptoms or discomforts were experienced?

Are you aware of others with similar symptoms? Yes No If yes, list names and contact information: What do you think the possible cause(s) are or have you observed any building conditions that might need attention (e.g. temperature, humidity, drafts, or odors)?

Do you have any health conditions that may raise susceptibility to environmental problems? Contact lenses Chronic cardiovascular disease Chemo or radiation treatment Allergies (Describe) Chronic respiratory disease (Asthma) Immune system deficiencies Chronic neurological disease Sinus Infection Other Time When did the symptoms start? When are they the worst? Do they go away? If so, when? Have you noticed any other events (weather, temperature, humidity, construction) that could have contributed to their symptoms (describe)? Location Where are you when symptoms are experienced? Where do you spend most of their time in the building? Additional Information Have you sought medical attention: Yes No Do you smoke: Yes No Have there been any changes in your work space or nearby offices in the past 3 months (new carpeting, new furniture, etc.)?

Describe any odors or smells: No noticeable smell Natural gas Sewer gas smell Wet dirt Burning odor Chemical smell Moldy or musty odor Other Send the completed form to EH&S at T-1475 or call X7233 for further assistance. Updated 8/2012