IAQ Complaint Information Collection Form

Person Completing Information:______Campus/ Work Unit: ______

Contact Email: ______Phone: ______Date(s)/Review Period: ______

  1. PROBLEM/CONCERN INFORMATION Date Conditions First Noticed: ______

Description – Nature of IAQ problem/concern: ______

______

Are conditions repetitive or cyclical? Yes No (circle one)

Describe pattern or time(s) of day?______

Work Area (s) Affected (list with numbers persons per work area where complaints received):

______

______

Work Area Liaison or Contact Person(s):

______

Workspace temperature (check):  Too hot  Too cold  Too humid  Too dry  Drafty  Too stale

Describe: ______

Other notable environmental factors/observations:  Odors  Excessive dust  Excessive moisture?

 Mold  Other: ______

Describe: ______

Recent activities near or within the work area (check as appropriate, indicate dates)?

Construction: ______/  Increase/decrease # occupants: ______
Heating/cooling system change:______/ Outdoor mulch, lawn care, chemicals: ______
Building layout/use change: ______/ Carpet cleaning: ______
Flooring changes: ______/  New furniture/furnishings: ______
Recent water incursion/leaks: ______/ Windows/opening: ______
 Indoor chemical use: ______/  Other:
  1. HEALTH-RELATED SYMPTOMS OR COMPLAINTS INFORMATION

Building/Unit Contact Person: ______Contact Ph./Email ______

Describe reported symptoms by affected persons:

______

______

______

2.HEALTH-RELATED SYMPTOMS OR COMPLAINTS (cont.)

Symptoms first reported (Date)?______Time of Day? ______

Pattern of symptoms reported? Yes No (circle one)

Describe (regardless of pattern): ______

______

Symptoms reported to subside after leaving work? Yes No (circle one)

Describe: ______

Symptoms coincident with building activities, events, seasons, outdoor conditions?(examples: floor cleaning, construction, smoking, grass cutting, food preparation/cooking, mechanical work, heating systems, etc.) Yes No(circle one)

Describe: ______

______

Affected person(s)sought medical support regarding symptoms? Yes No(circle one)

Personal care physician or medical support? Yes No (circle one)

Penn State First Report of Injury (FROI) submitted? Yes No (circle one)

Penn State Occupational Medicine or designated panel provider consulted? Yes No (circle one)

Affected Employee Supervisor(s) or Safety Officer(s) to contact for more information: ______

______

Employee(s)indicate availability to discuss symptoms? Yes No(circle one)

  1. ADDITIONAL INFORMATION

______

Page 1 of 2 EHS IAQ Information Form 11-2017