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Request for Indoor Air Quality Investigation
Request for Indoor Air Quality Investigation
Occupant Name:
(Required)
First
Last
Date:
(Required)
MM slash DD slash YYYY
Email Address:
(Required)
Enter Email
Confirm Email
Department:
(Required)
Phone Number:
(Required)
Supervisor Name:
(Required)
First
Last
Building:
(Required)
Room Number(s) or Specific Location(s):
(Required)
Symptom Patterns
What kind of symptoms or discomfort are you experiencing?
(Required)
Are you aware of other people with similar symptoms or concerns?
(Required)
Yes
No
List name(s) and location(s) of other people with similar symptoms or concerns.
(Required)
Do you have any health conditions that may make you particularly susceptible to environmental problems?
(Required)
Yes
No
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)
Have you sought medical attention for your symptoms?
(Required)
Yes
No
Other Comments:
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