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Environmental Health and Radiation Safety forms

Indoor Air Quality Occupant Questionnaire

Indoor Air Quality Occupant Questionnaire

Any IAQ concern that poses an immediate danger to life and health should be reported to Campus Safety Services at 215-204-1234 (1-1234).
Occupant Information
Occupant Name*
First Last
Phone*
Email*
Building Name*
Room Number*
Symptoms
What is/are your chief complaint(s)?*
What symptoms or discomforts were experienced?
Do you have any health conditions that may raise susceptibility to environmental problems?
- Yes
- No
Have you sought medical attention?
- Yes
- No
Do you smoke?
- Yes
- No
Time
When did the symptoms start?
When are they the worst?
Do they go away?
- Yes
- No
If yes, when?
Have you noticed any other events (weather, temperature, humidity, construction) that could have contributed to the symptoms?
- Yes
- No
If yes, please list the events here.
Location
Where are you when symptoms are experienced?
Where do you spend most of the time in the building?
What do you think the possible cause(s) are or have you observed any building conditions that might need attention (e.g. temperature, humidity, drafts, or odors)?
Have there been any changes in your work space or nearby offices in the past 3 months (new carpeting, new furnitute, etc.)?
- Yes
- No
If yes, please list the changes here.
Additional Information
Some common problems are listed below. Please check any that apply to your situation:
- Lack of fresh air
- Natural gas
- Sewer gas smell
- Dust in the air
- Burning odor
- Chemical smell
- Visible mold
- Moldy or musty odor
- Other
Other
Please provide any other comments or observations that may be helpful in determining the environmental condition of your workspace.
Environmental Health and Radiation Safety will only use the provided information to appropriately respond to your request. EHRS will not sell your information or use it for marketing purposes. Please contact us at 215-707-2520 or ehrs@temple.edu with any questions about how your information is used.

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