Allergen/Toxic Mold Indoor Air Quality Investigation Questionnaire
- - CONTENTS: Building indoor air quality questionnaire form © Copyright 2010 InspectAPedia.com
- Building-Related Health or IAQ Complaint recording & diagnostic checklist: Mold, odor, allergy, other complaints
- POST a QUESTION or READ FAQs about what questions to ask when collecting indoor air quality complaints & surveys of building occupants
Here is a sick building questionnaire form helpful in tracking down building-related indoor air quality and health complaints that may be related to building conditions.
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Allergen/Toxic Mold Indoor Air Quality Investigation Questionnaire Form
Mail or give this questionnaire to your building investigator or consultant
Write-in or circle information below as appropriate.
Copying of this form is permitted as needed provided no changes are made to this document
without permission. Contact us to suggest changes/additions to the form. © 2012 - 1985 Daniel Friedman, All Rights Reserved.
Name:____________________________________________________ Tel: __________________
Complaints/Symptoms (Per occupant):
Complaint type (circle):
Chills, Cough, congestion, chest tightness, dizziness, eye irritation,
fatigue fever, headache, itching, lethargy, nausea, nose irritation
odors/smells, shortness of breath, sinus irritation, sleepiness, swelling,
temperature/hHumidity (discomfort), throat irritation
Other (describe): ___________________________________________________________________________
Medical diagnoses: infection, immunocompromised, clusters of serious health concerns
suspected cause or contributor____________________________________
Don't Know ______
of day/season when more severe: Morning EveningNo Difference This is your home workplace both
Symptoms Started:______________________ Years occupying subject building:________
Profession/Job:______________________________ Other Exposures at home/work:___________
per day in building _____How Long spent in each room________________________________
change when out of building? If so, how/how long?
Complaint started/stopped (date/time)
_________________ or Complaint is Ongoing: Yes ___ No____
Complaint Dates if recurrent, or first observed if ongoing ______________________________________
Lawn treated with pesticides
herbicides? This Lawn Neighbors_______________________
Distance to: Swamps/wetlands ______ Dry-Cleaners/Laundry______ Compost _____
Mildew or Molds growing on exterior? No. / Yes. Where?________________________
Building, or Lawn Pest
or Exterior treated for _________________ Date/Frequency___________________
ants Other Insects / Rodents_____________________________________
number of spider webs in basement/crawl space/building Yes No No Access
furniture treated for Mites Fleas Date/Frequency____________________
Building Information: Age:_____ Type
Of Structure: 1-Fam 2-FamMultiple Condo Office
Story 2-Story 3 StoryHigh-Rise: Your Floor:____________
Attached Under Detached Slab construction yes noOther_________________
Basement: None Finished Un-finished Both Crawl
space: None partial fulldirt cement no access
Area Wall-to-wall Material:
Wool Synthetic Don't know
Area Wall-to-wall Material:
Wool Synthetic Don't know
Area Wall-to-wall Material:
Wool Synthetic Don't know
cleaned _________ Method
Used: Steam Water Dry Chemical ________________
Used: (Particle board, adhesives,
carpeting, painting, etc.) __________________________
Soot/Dust/Leak Stains At:________________________________________________________________
Observed: Dates/Tiimes/Weather/Sunlight/Wind/Temperature/HVAC Operating:___________________________________________________
Observed: Odors Mold/Mildew
Soot/Dust/Leak Stains At:_________________________________________________________________
Observed: Dates/Tiimes/Weather/Sunligh/Windt/Temperature/HVAC Operating:___________________________________________________
leaks, insect or rodent pests)________________________________________________________________
House Fan: Yes Frequency of Use:_______________ Rarely or
Condensation: NoneLight Heavy No Access
Ventilation: None Gable-end/Roof Vent Fan Ridge Vent Soffit Vent Continuous? Obstructed?
Leaks: None PriorPresent Significant
Entry and Moisture History:__________________________________________
Mold/Mildew: visible @
___________________________________________ Odors Stains
Entry Signs: Partition
Walls Closets Carpets/Rugs Present
generally shut openvaries
basement used/occupied per week:______ Office Exercise space Other
Chemicals stored at:________________________________________________
Other leaks / Water Entry History
drainage ice dams gutter defects plumbing leaks sewage-backup
Furnace Hot Water
Boiler Steam Stove/Fireplace
Fuels: Oil Gas Electric Wood/Coal __________
Leak Puff-Back SpillageSoot/Dust Noises
Ductwork: Last Cleaned_________________
Return Ducts at:____________________
heaters in kitchen in bath
Filters: Fiberglass furnace filter Fiberglass media filter
Accordion Paper Filter Electronic
Frequency of changing/cleaning filters:________________________
(devices to add moisture to air, usually used in winter)
In-Room At-Furnace Leaks/Other
Dehumidifiers: (devices to remove moisture
from air, used in humid weather and/or damp locations)
Present in use Last cleaned_________Coil Condition_____
Type: Central Room-Units Located
Air Locations: ________________________________________________________
near: bathroom garageutility room Duct Type: metal insulated flexiblebuilding cavities
Insulation: fiberglass lining? Yes No Condition: _________ Cleaned?
Handling: Gravity drains Pumps Leaks? Yes No
Cleaned? Yes No
__________________ Vented to:____________________________
Machine at:_______________ Leak history___________________________
Gas ignition: Match
Refrigerator: Drip Tray missingpresent dirty Last Cleaned____________ Ice Maker Leaks?
Leaks Soil under
Pets (list all)___________________________________________________________
Benjamina (ornamental fig)
Bedding: Allergy control covers in use not apparentLinens washed in hot cold water.
Furniture: padded: cushions fleecy
Fragrances Hair Spray PerfumesAir Fresheners
lamps burned in
home Frequency_____________ Scented Candles Incense used?
cleaner type: Canister Upright /HEPA filter? Brand:______________
Service yes uses their own vacuum cleaner? Yes No
Any other comments about sources of
these complaints) consultation has also been with
Medical ProfessionalIndustrial Hygienist Home
Inspector No One Else
Attach Sketchs: floor plan, building plan, photographs, indicating areas of complaints, suspected causes or sources of complaints.
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Continue reading at MOLD CLEANUP GUIDE- HOW TO GET RID OF MOLD or select a topic from the More Reading links or topic ARTICLE INDEX shown below.
Green link shows where you are in this article series.
- ACTION GUIDE - WHAT TO DO ABOUT INDOOR MOLD
- AIR QUALITY on COMMERCIAL AIRCRAFT
- AIRBORNE PARTICLE ANALYSIS METHODS
- ALLERGEN TESTS for BUILDINGS
- BIOLOGICAL POLLUTANTS
- BLACK MOLD, HARMLESS
- CAR SMELL - Mold DEODORIZING
- CARPET DUST IDENTIFICATION
- CARPET MOLD CONTAMINATION
- CARPETING & INDOOR AIR QUALITY
- COSMETIC MOLD, RECOGNIZE
- CRAWLSPACE MOLD ADVICE
- CULTURE PLATE Test Errors, Mold
- DRYWALL MOLD TESTING
- DUST SAMPLING PROCEDURE
- ENVIRONMENTAL TEST ERROR TYPES
- FIBERGLASS PARTICLE CONTAMINATION TEST
- FUNGICIDAL SPRAY & SEALANT USE GUIDE
- HIDDEN MOLD, HOW TO FIND
- HOUSE DUST ANALYSIS
- HOUSE DUST COMPONENTS
- MOLD: A COMPLETE GUIDE - home
- MOLD APPEARANCE - WHAT MOLD LOOKS LIKE
- MOLD APPEARANCE - STUFF THAT IS NOT MOLD
- MOLD ATLAS & PARTICLES INDEX
- MOLD in BUILDINGS
- MOLD CLEANUP GUIDE- HOW TO GET RID OF MOLD
- MOLD CLEARANCE INSPECTIONS
- MOLD CULTURE TEST KIT VALIDITY
- MOLD DETECTION & INSPECTION GUIDE
- MOLD on DIRT FLOORS
- MOLD / ENVIRONMENTAL EXPERT, HIRE ?
- MOLD FREQUENCY in BUILDINGS
- MOLD GROWTH on SURFACES
- MOLD KILLING GUIDE
- MOLD LEVELS
- MOLD by MICROSCOPE
- MOLD PREVENTION GUIDE
- MOLD SAMPLE POINT CHOICES
- MOLD TEST KITS
- MOLD TEST KIT INSTRUCTIONS
- MOLD TEST vs. PROBLEM DIAGNOSIS
- MOLD TEST REASONS
- MOLD TESTING & SAMPLING MISTAKES
- MOLD TESTING SERVICES
- MOLD TESTING METHOD VALIDITY
- ODORS GASES SMELLS, DIAGNOSIS & CURE - home
- OZONE MOLD / ODOR TREATMENT WARNINGS
- STAINS on & in BUILDINGS, CAUSES & CURES
- STAINS on INDOOR SURFACES, PHOTO GUIDE
- TAPE & BULK SAMPLING & TESTS for MOLD
- TEST KITS for DUST, MOLD, PARTICLE TESTS
- VACUUM CASSETTE FILTER SAMPLE TESTS for DUST / MOLD
- WATER ENTRY in BUILDINGS
- WOOD FLOOR DAMAGE
- FAQs below discusses field reports of problems & solutions for this topic
Frequently Asked Questions (FAQs)
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Technical Reviewers & References
Publisher's Google+ Page by Daniel Friedman
Click to Show or Hide Citations & References
- Origianal questionnaire design: ©Daniel Friedman, with discussion & advice from other field and laboratory investigators
- US EPA - Mold Remediation in Schools and Commercial Building [Copy on file at /sickhouse/EPA_Mold_Remediation_in_Schools.pdf ] - US EPA
Allergies, Allergens, Allergy Testing in Buildings - References & Products
- Air Conditioning System Blower Fans & Filters Cascading for Optimum Indoor Air Quality
- Allergen Tests in Buildings advice about how to test, what to look for, in evaluating the level of dog, cat, or other animal allergens in a building
- "IgG Food Allergy Testing by ELISA/EIA, What do they really tell us?" Sheryl B. Miller, MT (ASCP), PhD, Clinical Laboratory Director, Bastyr University Natural Health Clinic - ELISA testing accuracy: Here is an example of Miller's critique of ELISA
http://www.betterhealthusa.com/public/282.cfm - Townsend Letter for Doctors and Patients
The critique included in that article raises compelling questions about IgG testing assays, which prompts our interest in actually screening for the presence of high levels of particles that could carry allergens - dog dander or cat dander in the case at hand.
http://www.tldp.com/issue/174/IgG%20Food%20Allergy.html contains similar criticism in another venue but interestingly by the same author, Sheryl Miller. Sheryl Miller, MT (ASCP), PhD, is an Immunologist and Associate Professor of Basic and Medical Sciences at Bastyr University in Bothell, Washington. She is also the Laboratory Director of the Bastyr Natural Health Clinic Laboratory.
- Allergens: Testing for the level of exposure to animal allergens is discussed at http://www.animalhealthchannel.com/animalallergy/diagnosis.shtml (lab animal exposure study is interesting because it involves a higher exposure level in some cases
- Allergens: WebMD discusses allergy tests for humans at webmd.com/allergies/allergy-tests
- Animal Allergens: Dog, Cat, and Other Animal Dander - Cleanup & Prevention Information for Asthmatics and regarding Indoor Air Quality.
- Atlas of Mold Related Illness Symptoms & Complaints - long list of both documented, studied mold related illness, and complaints ascribed to mold contamination or allergens in buildings
- Cat Dander: how to inspect and test a building for past or current presence of cats, cat hair, cat dander, and cat allergens
- Clinical Atlas of Mold Toxicity - An Online Description of Toxic, Pathogenic, Allergenic Fungi, Fungal Diseases
- Fiberglass Insulation Contains Mold© 2005 comments about a field study in process, & more about health hazards from fiberglass insulation
- Humidity: What indoor humidity should we maintain in order to avoid a mold problem?
- Mold Action Guide detailed guide on finding, removing, and preventing indoor mold contamination
- Odors, Odor Detection, Smells, & Gases how to find and identify sources of noxious or toxic odors and gases
- Other environmental risks, Our much longer list: Asbestos, carbon monoxide, electromagnetic fields, etc.
- Ozone: The Use of Ozone Indoors for Control of Odors and Mold
Removal in Buildings: A Summary of Hazards and False Claims.
- Pollen Allergens: identification, plant pollen and indoor air quality
- Products to Reduce Mold & Allergy Problems to reduce indoor mold or allergen levels: air cleaners, air purifiers, dust mite covers, vacuum cleaners, crawl space vents
- Recognizing Allergens: What various indoor allergens look like - identification photos to help identify pollen, dust mites, animal dander, toxic or allergenic mold - Common Mold and other Allergens, Irritants, Remedies & Advice
- Rodent control issues, including dander, fecal, and urine contamination of Buildings and Building insulation are discussed at our
- Sewage and Septic backup contamination in Buildings: inspection, testing, remediation, & references to expert sources
- Action Guide: What to do about mold, mildew, and other indoor allergens
Mold Contamination Testing, Cleanup, Prevention: references & products
- The Mold Information Center: What to Do About Mold in Buildings, When and How
to Inspect for Mold, Clean Up Mold, or Avoid Mold Problems
- Aerobiology, Building Science, Microscopy, & Laboratory References, an extensive technical bibliography
- Allergens: what they look like in buildings
- Associations: Sick House, Sick Building, SBS - Air Quality, Government, Private Associations and Information Resources
- Atlas of Clinical Fungi, 2nd Ed., GS deHoog, J Guarro, J Gene, & MJ Figueras, Centraalbureau voor Schimmelcultures, Universitat Rovira I Virgili, 2000, ISBN 90-70351-43-9 (you can buy this book at Amazon) - The Atlas of Clinical Fungi is also available on CD ROM
- Atlas of Mold Related Illness: Index of Symptoms and health, physical, neurological, psychological, and other complaint which people suspect may be mold or building-related.
- Atlas of Indoor Mold, Online Clinical Mold Atlas, Toxins, Pathogens, Allergens and Other Indoor Particles - Medical Health Effects of Mold (separate online document)
- Black Mold that is Harmless Photos of recognizable, usually harmless black mold on wood, bluestain, ceratocystis, ophistoma
- Building Floods: quick steps after a building flood or plumbing leak can prevent costly mold contamination
- Classes of Mold: what types of cosmetic, allergenic, or toxic mold are a problem? Can mold be cleaned-up successfully?
- Clinical Mold References - Detailed bibliography of mold reference texts
- "A Brief Guide to Mold, Moisture, and Your Home", U.S. Environmental Protection Agency US EPA - includes basic advice for building owners, occupants, and mold cleanup operations. See http://www.epa.gov/mold/moldguide.htm
- "Disease Prevention Program for Certain Vegetable Crops," David B. Langston, Jr., Extension Plant Pathologist - Vegetables, University of Georgia (PDF document) original source: www.reeis.usda.gov/web/crisprojectpages/209797.html
- "Disease Prevention in Home Vegetable Gardens,"
Department of Plant Microbiology and Pathology,
Department of Horticulture, University of Missouri Extension - extension.missouri.edu/publications/DisplayPub.aspx?P=G6202
- "Management of Powdery Mildew, Leveillula taurica, in Greenhouse Peppers," Ministry of Agriculture and Lands, British Columbia - Original source: www.agf.gov.bc.ca/cropprot/peppermildew.htm
- Environmental Health & Investigation Bibliography - our own technical library on indoor air quality inspection, testing, laboratory procedures, forensic microscopy, etc.
- Fiberglass: Mold in Fiberglass Insulation© 2005 comments about a field study in process, & more about health hazards from fiberglass insulation - DJF
- Fifth Kingdom, Bryce Kendrick, ISBN13: 9781585100224, is available from the InspectAPedia online bookstore - we recommend the CD-ROM version of this book. This 3rd/edition is a compact but comprehensive encyclopedia of all things mycological. Every aspect of the fungi, from aflatoxin to zppspores, with an accessible blend of verve and wit. The 24 chapters are filled with up-to-date information of classification, yeast, lichens, spore dispersal, allergies, ecology, genetics, plant pathology, predatory fungi, biological control, mutualistic symbioses with animals and plants, fungi as food, food spoilage and mycotoxins.
- Fungi, Identifying Filamentous, A Clinical Laboratory Handbook, Guy St-Germain, Richard Summerbell, Star Publishing, 1996, ISBN 0-89863-177-7 (English) (buy at Amazon)
- MOLD in BUILDINGS Procedure: what mold is often found where in buildings - simple technical presentation
- Meruliporia: the house eating fungus or "poria"
- MOLD ACTION GUIDE Step-by-Step Instructions, What to do about mold, mildew, and other indoor allergens
- MOLD APPEARANCE - WHAT MOLD LOOKS LIKE Photos of what mold looks like in buildings
- MOLD APPEARANCE - STUFF THAT IS NOT MOLD Photos of NOT-mold material that is sometimes mistaken for mold
- MOLD ATLAS & PARTICLES INDEX, Pathogens, Allergens and Other Indoor Particles - Medical Health Effects of Mold (separate online document)
- MOLD BY MICROSCOPE Mold under the microscope - photo identification of the most common indoor molds found in buildings
- Mold FAQs Answers to Most Questions about Indoor Mold, Mold Related Illness, Mold Cleanup, Mold Prevention
- US EPA: Mold Remediation in Schools and Commercial Building [Copy on file at /sickhouse/EPA_Mold_Remediation_in_Schools.pdf ] - US EPA
- Mold spores in the Home - a Photo ID Library for detection and identification of mold allergens
- Mold Test Kits - How to Collect and Send Your Own Mold Sample to our mold testing lab or to any mold lab you wish
- Most Common Indoor Molds Found in Buildings, A Table of
- Mycology, Fundamentals of Diagnostic, Fran Fisher, Norma B. Cook, W.B. Saunders Co. 1998, ISBN 0-7216-5006-6 (buy this book at Amazon)
- Ozone Warnings - Use of Ozone as a "mold" remedy is ineffective and may be dangerous.
- Rot concerns in buildings-some building mold such as Meruliporia incrassata "Poria" risks serious rot and hidden structural damage
- US EPA: Una Breva Guia a Moho - Hongo [Copy on file as /sickhouse/EPA_Moho_Guia_sp.pdf - en Espanol
OTHER IAQ ISSUES: How To Find and Address Other Indoor Air or Indoor Environment Contaminants Besides Mold
Mold or allergens may not be the only or even the main indoor environmental contaminant. Don't let media attention to mold
cause so much enviro-scare fear that other, possibly more urgent hazards go un-addressed.
- Fiberglass building insulation and HVAC duct work insulation hazards
- Sewage and Septic backup contamination in buildings: inspection, testing, remediation, & references to expert sources
- Other environmental risks: Asbestos, carbon monoxide,
electromagnetic fields, environmental illness, fiberglass, MCS - multiple chemical sensitivity, toxic gases, etc
- Indoor Gas Sampling Plan
for Residential Buildings lists a number of toxic indoor gases which we test for, depending on the building
complaint and building conditions
- Ozone Warnings - Use of Ozone as a "mold"
remedy is ineffective and may be dangerous.
- Pet control - if you can't say goodbye to your bird, cat, dog, guinea pig, hamster, tropical fish, then limit the
areas they occupy and limit the airflow from that area to sleeping or other areas of the building, use allergenic
bedding, eliminate wall-to-wall carpeting, improve housecleaning including use of a HEPA-rated vacuum cleaner. For more details
see our article Dog, Cat, and Other Animal Dander - Information for Asthmatics and Indoor Air Quality
- Rodents, Mice, Squirrel Control - I find high levels of mouse and rodent dander, fecal dust, and urine-contaminated dust in some buildings,
and high levels of these materials in building insulation in those locations. If you have a mouse problem, particularly if mice and their waste (fecals or urine) are contaminating
the building HVAC or building insulation, may need both steps to clean up or remove infected materials and steps to stop an ongoing
rodent problem. If squirrels are a problem, the cleanup needs to include closing off entry openings into the building. Get some
help from a licensed pest control expert.
Books & Articles on Building & Environmental Inspection, Testing, Diagnosis, & Repair
- Environmental Health & Investigation Bibliography - our technical library on indoor air quality inspection, testing, laboratory procedures, forensic microscopy, etc.
- Adkins and Adkins Dictionary of Roman Religion discusses Robigus, the Roman god of crop protection and the legendary progenitor of wheat rust fungus.
- Kansas State University, department of plant pathology, extension plant pathology web page on wheat rust fungus: see http://www.oznet.ksu.edu/path-ext/factSheets/Wheat/Wheat%20Leaf%20Rust.asp
- "A Brief Guide to Mold, Moisture, and Your Home",
U.S. Environmental Protection Agency US EPA - includes basic advice for building owners, occupants, and mold cleanup operations. See http://www.epa.gov/mold/moldguide.htm
- US EPA - Una Breva Guia a Moho - Hongo [Copy on file as /sickhouse/EPA_Moho_Guia_sp.pdf - en Espanol