Complaint Form- Manager Recorded

If you opt to collect IAQ 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: ______________________________

Overview

“Please give me an overview of the air quality problems that you are experiencing”.
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
“What do you think the problem is?” _____________________________________________________________________________________________________________________________________________________________________

Symptoms

(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? (e.g. allergies, chronic respiratory disease, undergoing chemotherapy, immune system suppressed by disease or other causes) _____________________________________________________________________________________________________________________________________________________________________

Patterns

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?”

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