This survey will help you detect the presence or absence of health problems in your building. Fill out this form, get your co-workers to fill it out as well, and review it to see where the major problems are, what are the typical health problems. See the NYCOSH Indoor Air Quality page for suggestions on how to proceed after doing a survey to solve your air quality problem.

Name:                                            Date:

Location in Building:

Phone number:

1. When did you begin working in this building?

2. When did you begin working at your present office location?

3. Are any of these a problem in the building?
(circle all that apply)

Temperature too hot                   Smoky air

Temperature too cold                  Stale air

Peculiar odors                            Soot by air vents

Stuffy air                                    Drafts

When are these a problem? Please describe where and when they are found (for example, is the problem seasonal, or only on Mondays, etc.)

4. Do you have any of the following health complaints?
(This is a list of symptoms that can be caused in buildings with air quality problems. Not all of these may be present in your building.)

____ Aching joints _____ Nausea

____ Back pain _____ Skin irritation/itching

____ Muscle twitching _____ Sneezing or coughing

____ Dizziness _____ Chest tightness

____ Hearing disturbances _____ Eye or nose irritation

____ Dry cough _____ Headache

____ Heartburn _____ Fatigue/drowsiness

____ Dry skin _____ Sore or dry throat

____ Shortness of breath _____ Nasal irritation or nosebleeds

____ Sinus congestion or runny nose _____ Skin rash

____ Chills or fever _____ Menstrual irregularities

Other (fill in)

5. When do these symptoms occur?

________Mornings _____Afternoons

________All day long ______No noticeable pattern

6. Are these symptoms worse on some days than others?
(examples: Tuesdays are bad, Thursdays are not)

Specify which days during the week:

7. Where in the building do these symptoms occur?
(check all that apply)

______At my desk _______In the lavatory

______In the lounge _______Other: specify

______No particular place _______________________

8. When did you first notice these symptoms?

9. Do you suffer from allergies (hay fever)?

_____Yes ______No

10. If yes, what time of year are you most affected?

11. Do you have any medical conditions?

______Yes ______No

If yes, please explain

12. Do you experience these symptoms?

______Only at work _______At work and at home

13. Have you had to leave work early or miss work because of these symptoms?

____No ___Yes ____How many times in the past month?

____How long were you out from work? (# of days)

14. When do you experience relief from these symptoms?

15. Have you seen a physician about these ailments:

____Yes ____No

If yes, when, and what did the doctor say?

16. Has a doctor told you that you have any of the following health problems? (check all that apply)

____Hay fever, pollen allergies ____Asthma

____Chronic bronchitis ____Chronic sinus problems

____Skin allergies, dermatitis

17. Have any of these gotten worse lately?

_____Yes _____No _____Which ones?

18. Do you smoke tobacco?

____Yes _____No Amount per day _____________

19. Do you seem to be getting more colds or flu than you normally might?

____Yes _____No

20. Has anything happened recently at your workplace that could affect the air quality?

21. What do you think is the cause of your symptoms or illness?
Other comments about the situation:

* other people smoking

* cleaning and maintenance

* temperature/ventilation

* renovations/construction

* presence of toxic chemicals

_________________________________________________________________

Click here for more links and news about indoor air quality.