Initial Data

Date complaint received ________________ Complaint received via ______________________

Location _____________________________ Contact person/complainant _________________

Nature of complaint _____________________________________________________________

_____________________________________________________________________________

Interview with Employee

Symptoms reported:

Cough___ Sneezing___ Shortness of breath___ Asthma___ Bronchitis___ Sore throat___ Watery eyes___ Nausea___ Rash___ Hives___ Lightheadedness___ Headaches___ Other___

When did the symptoms first start? ___________________________________________________

How often do they occur? __________________________________________________________

What time of day do they usually start? _______________________________________________

What time of day are they the worst? _________________________________________________

Is there any time you are symptom-free?_______________________________________________

When the symptoms first started, had anything changed in the building (construction, renovation, new carpet, new furniture)? __________________________________________________________________

_______________________________________________________________________________

Visual Inspection

Stained ceiling tiles___ Other evidence of water leaks___ Visible mold___ HVAC supply/return grills dusty or dirty___ Horizontal surfaces dusty___ Condition of carpet(new, worn, dirty, stained, etc.)___ Other____________________________

Temperature___ Relative humidity___%

Remediation:

Cleaning___ Dusting___ Disinfection___ Filter(s)___ HVAC modifications___ Other___________________________

Additional assessment needed (Industrial Hygienist, Health Department, etc.)

______________________________________________________________________________

Assessment completed by______________________________________Date________________

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