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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?

_______________________________________________________________________

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