Indoor Air Quality Report Form

Date

Work Area
(floor/department/location)

Symptoms experienced by individual
(eg. headache, dizziness, fatigue, sinus congestion, allergies, wheezing, blurred vision, eye nose and throat irritation, shortness of breath, nausea, etc.)

Times of day symptoms are experienced

History of symptoms
(When were they first noticed?)

Building condition that may be related to indoor air quality problem
(renovation, ventilation, humidity, new equipment, etc.)

Work activities and process that you may associate with release of contaminants.

Reported by