Request for Indoor Air Quality Investigation - Environment, Health and Safety

Date:(Required)

Department:(Required)

Phone:(Required)

Building:(Required)

Room Number(s) or Specific Location(s):(Required)

What mold growth have you observed?(Required)

What type of HVAC system supplies your location?(Required)

e.g., window unit or central AC

Symptom Patterns

What kind of symptoms or discomfort are you experiencing?(Required)

List name(s) and location(s) of other people with similar symptoms or concern:(Required)

Timing Patterns

When did your symptoms start?(Required)

When are they generally the worst?(Required)

Do they go away? If so, when?(Required)

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?(Required)

Spatial Patterns

Where are you when you experience symptoms or discomfort?(Required)

Where do you spend most of your time in the building?(Required)

Additional Information

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, recent painting, new carpet or furnishings)? Has there been recent remodeling or changes in your home environment (e.g., painting, new carpet and/or furniture)? Please explain.(Required)

Can you supply pictures of your concerns?

Drop files here or

Max. file size: 98 MB.