IUPUI Environmental Health & Safety


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Indoor Air Quality > Indoor Air Quality Questionnaire

Name:		Department:
Building & Room #:		Phone:
		Email:

Some people are concerned about their work environment. In order to investigate these complaints, we would like your cooperation in filling out this questionnaire. Your responses will be kept confidential.

1. Do you have air quality complaints? Yes No If No, please check No and submit this form to EHS If Yes, please check appropriate items as follows:
	lack of air circulation (stuffy feeling) noticable odors - please describe dust in the air other (specify)

2. When did these problems begin and when do they occur?
	month/year when problem began morning daily afternoon specific day(s) of the week all day which day(s)? no noticeable trend specific time of year which month(s)?

3. What health symptoms have you experienced? Select symptom(s) which you have experienced more than 2 times per week that may be related to working in this building.

Congestion; Chest-Tightness; Dry/Sore-Throat ; Fatigue ; Headache
Itching/Irritated-Eyes ; Nausea; Runny-Nose ; Shortness of Breath

Do these symptoms clear up within 1-2 hours after leaving work? Yes No If no, do they clean up over night or over the weekend? Yes No If all symptoms do not clear up when away from the building, which symptoms persist (at home or work) throughout the week? Select symptom(s) from the dropdown list and click on the " =>> " button to put it in the text box, and select another symptom from the dropdown list to add more symptoms. In the text box, you can delete the selected symptom(s). Have you sought medical attention for your symptoms? Yes No If yes, please describe Do you have any allergies or other health problems that may account for any of the listed symptoms? Yes No If yes, please describe Have any of your symptoms reduced your ability to work, caused you to stay home from work or caused you to leave work early? Yes No If yes, please explain How many hours per day do you spend in this building? How many hours per day at your work station?

4. Do any of the following apply to you?
	wear contact lenses operate video display terminals? How many hours per day? operate photocopier machines at least 10% of the day use or operate other office machines or equipment that may lead to health problems? Specify currently taking medication? Reason for medication

5. Do you smoke? Yes No

6. What is your job title or position?

7. Briefly describe your primary job tasks.

8. Please list your hobbies.

9. Can you offer any other comments or observations that may be helpful in determining the environmental condition of your workplace?

Contact Us:
Please select your topic of interest from the menu on top. If you have a question or concern that is not on the menu, please telephone our office, submit your correspondence to the address listed above, or use the Contact Email Form to send an email to EHS.

If you have any questions for EHS, please e-mail: IUPUI Environmental Health & Safety.
If you have any questions about this site, please contact Colleen McCormick at 278-1308, or by email at cjmccorm@iupui.edu.