The first step in battling Indoor Air Quality issues is to diagnose the problem. To help you do that, ask your employees to complete the survey below.

Initial Data

Employee Name ________________________________________________

Position _______________________________________________________

Location ______________________________________________________

Normal days/hours of work ________________________________________

Nature of complaint ______________________________________________

Details of Complaint

Symptoms noted:

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

Explanation of any item(s) checked above: ____________________________

______________________________________________________________

______________________________________________________________

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? ______________________________

What if any condition(s) aggravate the symptoms? _______________________

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

_______________________________________________________________

_______________________________________________________________

Are there any other details that you feel may help in the resolution of this issue?

_______________________________________________________________

_______________________________________________________________

Thank you for your help.

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