Complaint Form- Manager Recorded

From IAQforms

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.

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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?

Spacial Patterns
-Where are you when you experience symptoms or discomfort?
-Where do you spend most of your time in the building?

Additional Information -Do you have any observations about building conditions that might help explain your symptoms (e.g. temperature, humidity, drafts, stagnant air, odors)?
-Do you have any other comments?