Indoor Air Quality Survey

      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.

       

      Location

      Office of Administrative Affairs 
      330 Hyer Hall
      800 West Main Street
      Whitewater, WI 53190
      Phone:  262-472-1292

      54.167.10.244
      http://www.uww.edu/