Request for Mold Investigation - Environment, Health and Safety

Occupant Name:(Required)

First Last

Date:(Required)

Email Address:(Required)

Enter Email Confirm Email

Department:(Required)

Phone Number:(Required)

Supervisor Name:(Required)

First Last

Building:(Required)

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

Mold Concern

What mold growth have you observed?(Required)

Do you have any observations about building conditions that might need attention or might help explain the concern (e.g., temperature, humidity, stagnant air, odors, flood or water damage?(Required)

What type of HVAC system supplies your location (e.g., window unit or central AC)?(Required)

Are you experiencing any symptoms associated with your concern?(Required)

Yes

When did your symptoms start?(Required)

When are they generally the worst?(Required)

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

Are you aware of other people with similar symptoms or concerns?(Required)

Yes

Provide names and locations of those other people with similar symptoms and concerns:(Required)

Do you have any health conditions that may make you particularly susceptible to environmental problems?(Required)

Yes

Additional Information

Have you sought medical attention for your symptoms?(Required)

Yes

Other Comments: