Emergency NumbersPhone Book (Must be on-campus or have a valid network account)
Date
File No.
Building Name
Occupant Name
Address
Work Area (floor/department/location)
What kind of symptoms are you experiencing? (eg. headache, dizziness, fatigue, sinus congestion, allergies, wheezing, blurred vision, eye nose and throat irritation, shortness of breath, nausea, etc.)
Are you aware of other people with similar symptoms/conditions? Yes No
If so, what are their names and locations?
Do you have any health conditions that may make you particularly susceptible to environmental problems? (check all that apply)
Contact lenses
Allergies
Chronic cardiovascular disease
Chronic respiratory disease
Chronic neurological problems
Undergoing chemotherapy or radiation therapy
Immune system suppressed by disease or other causes
When did your symptoms start?
When are they generally the worst?
Do they go away? If so, when?
Have you noticed any other events (such as weather events, temperature or humidity changes, or activities in the building) that tend to occur around the same time as your symptoms?
Where are you when you experience symptoms or discomfort?
Where do you spend most of your time in the building?
Do you have any observations about building conditions that might need attention or might help explain your symptoms (e.g., temperature, humidity, drafts, stagnant air, odors)?
Have you sought medical attention for your symptoms?
Do you have any other comments?
