Complaint Form- Manager Recorded

If you opt to collect complaint information by brief interview rather than self-submitted forms, use the worksheet below. It is adapted from Building Air Quality, A Guide for Building Owners and Facility Managers by the US Environmental Protection Agency, 1991.


Address of Building: ______________________________
File Number: ______________________________
Complainant Name: ______________________________
Work Location: ______________________________
Completed by: ______________________________
Date: ______________________________
Please give me an overview of the IAQ problems that you are experiencing.
Symptom Patterns (be sure to have a privacy policy in place before collecting this information)
-What type of symptoms or discomfort are you experiencing?
-Are you aware of other people with similar symptoms or concerns?
-Does anything make you particularly sensitive or susceptible to the IAQ problem? Examples may include:

  • allergies
  • chronic respiratory disease
  • undergoing chemotherapy
  • immune system suppressed by disease or other causes

Timing Patterns
-When did your symptoms or discomfort start?
-When are they generally worst?
-Do they go away? If so, when?
-Are there any patterns to your symptoms? Do any events occur around the same time as your symptoms? 

Unlock the rest of this page by entering in the password.
This content is for students and clients of Indoor Sciences only.
Not a student or client of ours? Become one! Call us at (312)920-9393.
Take a class or have Ian Cull review your reports.

If you are a past student, EMAIL us to get the password.

Leave a Reply

Your email address will not be published. Required fields are marked *