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 InformationOccupant Name* First Last Phone*Email* Building Name* Room Number* SymptomsWhat 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 TimeWhen 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.LocationWhere 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 InformationSome 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 email@example.com with any questions about how your information is used.