Indoor Air Quality Interview Form


1.  Building:    
2.  Room Number:   
3.  Occupant Name (Last, First, Middle Initial):   
4a.  Completed By (Last, First, Middle Initial):    
4b.  Title:    4c.  Date:    

Symptom Patterns


5.  What kind of symptoms or discomfort are you experiencing?
       

5b. Are you aware of other people with similiar symptoms or concerns?
 
5c. If "Yes" to 5b, what are their names and locations?
       


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

     
 
  

Timing Patterns


7.  When did your symptoms start?
        
8.  Where are they generally worst?
        
9.  Do they go away?  If so, when?
        
10. 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?
        

Spatial Concerns


11. Where are you when you experience symptoms or discomfort?
        

Additional Information


12. 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)?
        
13. Have you sought medical attention for your symptoms?
       
13b. Have you obtained relief as a result of this medical attention?
 
14. Any other comments?
       

 

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