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: ______________________________
Please give me an overview of the IAQ problems that you are experiencing.
-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:
- chronic respiratory disease
- undergoing chemotherapy
- immune system suppressed by disease or other causes
-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?