Indoor Air Quality Questionnaire Please fill this form out and click "Submit" at the bottom of the page, or fax it to: (413) 542-5789 Attn: Richard Mears Environmental Health and Safety Amherst College Facilities Building Name: Room / Area: Address: Occupant Name: Work Location: Phone Number: Completed by: Title: Date: Symptom Patterns What kind of symptoms or discomfort are you experiencing?: Are you aware of other people with similar symptoms or concerns? 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? Contact lenses Chronic respiratory disease Chronic Neurological Problems Allergies Chronic Cardiovascular disease Immune system suppressed by disease or other causes Undergoing chemotherapy or radiation Timing Patterns When did your symptoms start?: When are your symptoms generally worst?: Do they go away? If so, when?: Have you noticed any other events that tend to occur around the same time as your symptoms?: (This could include weather events, temperature/humidity changes, or activities in the building) Spatial 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 the building conditions that might need attention/explain your symptoms?: (e.g. temperature, humidity, drafts, stagnant air, and odors) Have you sought out medical attention for your symptoms? Yes No Do you have any other comments?: Play validation audio Enable Javascript for audio controls Refresh validation image What text is in the image?: Enter the characters shown in the image or use the speaker icon to get an audio version.