skip navigation

Indoor Air Quality Survey

Name:
Department:
Building/Room #:
Office Phone:
E-mail:

1. Area or room where you spend the most time in the building:

2. Gender: Male Female

3. Age:

Under 25 45-54
25-34 55 or over
35-44

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. Submit this form by clicking the submit button below. Thank you for your cooperation. If you checked the Dissatisfied box, please complete the rest of this form.

5. Do any of your work activities produce dust or odor? Yes No

If yes, please provide more information:

6. Number of persons sharing same room:

7. Number of windows in room:

8. Do windows open? Yes No

9. Please rate adequacy of work space per person: (1=Too Little - 5=Too Much)

1 2 3 4 5

10. How long have you worked:

In this room?
In this building?

11. Please describe why you are dissatisfied with the indoor quality within your work area.

12. Describe any other discomfort or concerns that you have regarding indoor air quality.

13. Are you aware of other people with similar concerns? Yes No

If so, what are their names and office locations?

14. Do you have any health conditions that may make you particularly susceptible to environmental problems?

Yes No

15. When did you first perceive a problem with the indoor air quality?

16. Please rate room temperature: (1=Too Cold - 5=Too Hot)

1 2 3 4 5

17. When do these problems usually occur?

Time of Day: Morning Afternoon Evening

Day of week: Sun Mon Tues Wed Thur Fri Sat

Month: Jan Feb Mar Apr May Jun Jul Aug Sept Oct Nov Dec

Season: Spring Summer Fall Winter

18. When are the problems generally worst?

19. Do symptoms disappear? Yes No

If yes, when?

20. 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?

21. Do you have any additional observations about your indoor working environment that might need attention or might help explain your observations and concerns?

22. Do you have any other comments regarding the indoor air quality in your work area?

THANK YOU FOR YOUR COOPERATION.

Your information will be submitted to the Risk Management Director.