Interior Air Quality Occupant Survey
Please answer the questions. All responses will be kept confidential. Thank you for your assistance and cooperation.
Building Name:_______________________________________________________
Address:____________________________________________________________
Name (optional):______________________________________________________
Age (optional):________________________________________________________
SYMPTOMS
Are you experiencing symptoms or discomfort within your workplace?
Yes____________No____________
If yes, what are your symptoms?
__________________________________________________________________
Have you sought medical attention for your symptoms?
Yes____________No____________
When did your symptoms start?
_______________________________________________________________________
When are they generally worse?
_______________________________________________________________________
Do they go away?
Yes____________No____________
If yes, when?
__________________________________________________________________
Have you noticed any other events (such as weather, temperature or humidity changess, or activities in the building) that tend to occur around the same time as your symptoms?
_______________________________________________________________________
Are you aware of other people with similar symptoms and concerns?
Yes____________No____________
If so, what are their names and work locations?
__________________________________________________________________
Do you have any health conditions that may make you more likely to react to environmental problems? Circle the related health conditions.
| allergies contact lenses suppressed immune system chronic respiratory disease |
cardiovascular disease chronic neurological problems undergoing chemotherapy or radiation therapy |
WORK LOCATION
Where are you when you experience symptoms or discomfort?
_______________________________________________________________________
Where do you spend most of your time in the building?
_______________________________________________________________________
Do you have any observations about building conditions that might need attention or might help explain your symptoms (e.g. temperature, humidity, draft, stagnant air, odors)?
_______________________________________________________________________
Do you have any other comments?
_______________________________________________________________________
