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INDOOR AIR QUALITY ASSESSMENT FORM
*Please note, required fields are in
red
.
You May Print and Fax This Form to: 631-867-3128
or You May Email This Form to: rcozzetto@lindenhurstschools.org
Are you completing this form for another individual?
Yes
No
If yes, please enter your contact information: Name, Phone, Email
PART I - Personal History of the Affected Individual
1a. Name:
1b. Phone:
1c. E-mail:
2. Sex:
Male
Female
3. Age Level:
Infant
Child
Adult
Senior Citizen
4. Have you ever been diagnosed or treated for any respiratory or allergic condition?
Yes
No
If YES, Please Explain, If NO, Please Skip to Question 5
Does the condition still exist?
Yes
No
If YES, When do you usually suffer from it? If NO, Please Skip to Question 5
Are you taking prescription medicine for this condition?
Yes
No
If YES, Please list medications, If NO, Please Skip to Question 5
5. Do you wear contact lenses?
Yes
No
6. Do you smoke?
Yes
No
Are you regularly in contact with other smokers
Yes
No
PART II - Job Specifications
7a. In which building is the issue occurring?
7b. In which room # is the issue occurring?
7c. In what area of the room is the issue occurring?
8. What is your job title?
9. During the course of the day are you in close proximity to computer terminals or photocopiers?
Yes
No
If YES, What is the frequency of this contact? If NO, Please Skip to Question 10
10. What other machinery or office equipment do you come in contact with? Please list equipment or enter "None" in the field provided.
PART III - Environmental Situations Occurring Within the Facility -Please check all situations below you have experienced& describe where appropriate
11. Unusual Odors?
Yes
No
If YES, please describe:
12. Uncomfortable Temperatures?
If YES, please describe:
13. Noticeable Dust in the Air?
Yes
No
14. Noises?
Yes
No
If YES, please Describe:
15. Mustiness or a Stuffy Feeling?
Yes
No
16. Excessive Humidity or Dryness?
Yes
No
17. Other. Please Explain:
18. Are there any specific time frames when the above situations occur?
PART IV - Symptoms or Health Reports
19. Please note below, in your own words, any symptoms or ailments that you have experienced on a recurring basis that you feel may be related to the building:
20. Do you notice any relation to the ailments you experience with the situations and time frames listed in section III? Please Explain Below or enter "No":
21. Which ailments or symptoms dissipate after leaving the facility? Please Explain Below or enter "None":
22. Which ailments or symptoms continue after leaving the facility and for how long? Please Explain Below or enter "None":
23. Are you aware or suspicious of anything that may be the cause of the environmental situations, symptoms or ailments described above? Please Specify What and Why Below or enter "No":
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