1. Area or room where you spend the most time in the building:
2. Gender: Male Female
3. Age
Under 25 25-34 35-44 45-54 55 or over
4. Overall, are you Satisfied or Dissatisfied with the indoor air quality within your work area?
If you checked the Satisfied box, do not complete the rest of this form. Please submit this form using the Submit button at the bottom of this form. Thank you for your cooperation.
If you checked the Dissatisfied box, please complete the rest of this form.
5. Do any or your work activities produce dust or odor? Yes No
If Yes, please explain:
6. Number of persons sharing the same room (estimate).
7. Number of windows in room (estimate).
8. Do the windows open? Yes No
9. Please rate the adequacy of work space per person:
10. How long have you worked: In this room? In this building?
11. What kind of symptoms or discomfort are you experiencing?
12. Are you aware of other people with similar symptoms or concerns? Yes No
If so, what are their names and location?
13. (Optional) Do you have any health conditions that may make you particularly susceptible to environmental problems? (Check all that apply.)
14. When did you first notice a problem with the indoor air quality?
15. Please rate the room temperature:
16. When do these problems occur? (Check any that apply)
17. When are the problems generally worst?
18. Do symptoms disappear? Yes No
If yes, when?
19. Have you noticed any other events (such as weather events, temperature or humidity changes, or activities in the building) that tend to occur around the same time as your symptoms?
20. Do you have any observations about building conditions that might need attention or might help explain your symptoms (e.g., temperature, humidity, drafts, stagnant air, odors)?
21. Do you have any other comments?
