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 Mobile ViewENVIRONMENTAL HAZARDS - INSPECT, TEST, REMEDY MOLD: A COMPLETE GUIDE to TEST CLEAN PREVENT ACCEPTABLE MOLD LEVEL ACTION GUIDE - WHAT TO DO ABOUT INDOOR MOLD ACTIVITY of MOLD in BUILDINGS AIRBORNE MOLD SPORE COUNT ACCURACY AIRBORNE PARTICLE ANALYSIS METHODS ALLERGEN TESTS for BUILDINGS ALLERGENS in BUILDINGS, RECOGNIZING ALLERGY & MOLD IAQ PRODUCTS ALLERGY TESTS for PEOPLE ALLERGY TEST ACCURACY ASBESTOS IDENTIFICATION IN BUILDINGS ATTIC MOLD BASEMENT MOLD BASEMENT MOLD WATER IMPACT BATHROOM MOLD BIBLIOGAPHY for ENVIRONMENTAL HEALTH, MOLD, IAQ BIOGAS PRODUCTION & USE BIOLOGICAL POLLUTANTS BLACK MOLD, HARMLESS COSMETIC BLACK MOLD, TOXIC & ALLERGENIC BLEACHING MOLD, Advice about BOOK MOLD, Moldy Book Cleaning BOOKSTORE - ENVIRONMENTAL BROWN HAIRY BATHROOM MOLD CACTUS FUNGI / MOLD CAR MOLD CONTAMINATION CARPET DUST IDENTIFICATION CARPET MOLD CONTAMINATION CARPET PADDING ASBESTOS, MOLD, ODORS CARPET STAIN DIAGNOSIS CARPET & other STAIN TESTS CARPET TEST PROCEDURE CARPETING & INDOOR AIR QUALITY CARPETING, SELECTION & INSTALLATION CAT DANDER in BUILDINGS CLEARANCE INSPECTIONS - MOLD CLEANUP EFFLORESCENCE, Salts & White / Brown Deposits FIBERGLASS INSULATION MOLD FIBERGLASS PARTICLE CONTAMINATION TEST FIELD INVESTIGATION SERVICE FIND MOLD, ESSENTIAL STEPS FIND MOLD in BUILDINGS, HOW TO FIRE DAMAGE vs MOLD DAMAGE FLOOD DAMAGE ASSESSMENT, SAFETY & CLEANUP FLOODS IN BUILDINGS-mold FUNGICIDAL SPRAY & SEALANT USE GUIDE GAS EXPOSURE EFFECTS, TOXIC GAS DETECTION & MEASUREMENT HOUSE DUST ANALYSIS HOUSEWRAP AIR & VAPOR BARRIERS HIDDEN MOLD, HOW TO FIND HUMIDITY CONTROL & TARGETS INDOORS INDOOR AIR HAZARDS TABLE INDOOR AIR QUALITY & HOUSE TIGHTNESS INDOOR AIR QUALITY IMPROVEMENT GUIDE INDOOR AIR QUALITY METHODS COMPARED INSULATION INSPECTION & IMPROVEMENT INSULATION MOLD ITCHY FABRICS LAB PROCEDURES MICROSCOPE TECHNIQUES LEED Building Designation & IAQ MEDIA BLASTING for MOLD REMOVAL METHANE GAS SOURCES MICROSCOPE DIGITAL PHOTOGRAPHY MILDEW in BUILDINGS ? MILDEW ERRORS - MOLD PHOTOS MILDEW REMOVAL & PREVENTION MOISTURE CONTROL in BUILDINGS MOLD: A COMPLETE GUIDE TO MOLD MOLD ACTION GUIDE - WHAT TO DO ABOUT MOLD MOLD APPEARANCE - WHAT MOLD LOOKS LIKE MOLD CLEANERS - WHAT TO USE MOLD CLEANUP GUIDE- HOW TO GET RID OF MOLD MOLD CONSULTANTS/INSPECTORS MOLD CULTURE TEST KIT VALIDITY MOLD DETECTION & INSPECTION GUIDE MOLD or INDOOR AIR EMERGENCY RESPONSE MOLD EXPERT, WHEN TO HIRE MOLD FAQ's MOLD ODORS, MUSTY SMELLS MOLD PREVENTION GUIDE MOLD RELATED ILLNESS GUIDE MOLD SAFETY WARNINGS MOLD SPRAYS, SEALANTS, PAINTS MOLD STANDARDS MOLD TEST KITS for DIY MOLD TESTS MOLD TESTING METHOD VALIDITY ODORS & SMELLS DIAGNOSIS & CURE OZONE HAZARDS PAINTS & COATINGS ODORS IN BUILDINGS PARTICLE SIZES & IAQ Particulates & Allergens Indoors Pesticide Exposure Hazards PET ALLERGEN REMEDIES PLASTIC CONTAINERS, TANKS, TYPES PLASTIC HEATER VENT PLASTIC ODORS-SCREENS, SIDING PLUMBING SYSTEM ODORS POLLEN Photographs RENTERS & TENANTS GUIDE TO MOLD SICK HOUSE IAQ QUESTIONNAIRE SEWAGE BACKUP, WHAT TO DO SEWAGE BACKUP TEST & CLEANUP SEWAGE BACKUP PREVENTION STAIN DIAGNOSIS on BUILDING INTERIORS STAINS on INDOOR SURFACES: PHOTO GUIDE STAINS & Thermal Tracking TECHNICAL & LAB PROCEDURES THERMAL TRACKING Indicates Heat Loss TRAPPED MOLD BETWEEN WOOD SURFACES VAPOR BARRIERS & CONDENSATION in BUILDINGS VENTILATION in buildings VINYL Siding or PLASTIC Window ODORS in buildings VINYL CHLORIDE HEALTH INFO WALL SIDING TRIM & FINISHES WALL FINISHES INTERIOR WATER BARRIERS, EXTERIOR BUILDING WATER ENTRY in buildings WATER ODORS, CAUSE CURE World Trade Center Collapse Dust Photos More Information |
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. InspectAPedia tolerates no conflicts of interest. We have no relationship with advertisers nor with topics or services discussed at this website.© Copyright 2012 InspectAPedia.com, All Rights Reserved. Information Accuracy & Bias Pledge is at below-left. Use page top links to major topics or use links at the left of each page to navigate within topics and documents at this website. Green links show where you are in a document series or at this website. Allergen/Toxic Mold Indoor Air Quality Investigation Questionnaire FormMail or give this questionnaire to your building investigator or consultant ____________________ Email: _____________________________________ Write-in or circle information below as appropriate.
Copying of this form is permitted as needed provided no changes are made to this document
Name/Company:___________________________________________ Date:_________________ Name:____________________________________________________ Tel: __________________ Address:__________________________________________________ ClientEmail:____________ ___________________________________________________ Inspector:_____________ Complaints/Symptoms (Per occupant): Occupant:___________________ Symptoms/Complaint:______________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ 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 Occupant's suspected cause or contributor____________________________________ Don't Know ______ ____________________________________________________________________________________________ Time of day/season when more severe: Morning EveningNo Difference This is your home workplace both When Symptoms Started:______________________ Years occupying subject building:________ Profession/Job:______________________________ Other Exposures at home/work:___________ Hours per day in building _____How Long spent in each room________________________________ ________________________________________________________________________________________ Symptoms 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 ______________________________________ __________________________________________________________________________________________
Exterior: Lawn treated with pesticides herbicides? This Lawn Neighbors_______________________ Building Distance to: Swamps/wetlands ______ Dry-Cleaners/Laundry______ Compost _____ Mildew or Molds growing on exterior? No. / Yes. Where?________________________
Building or Exterior treated for _________________ Date/Frequency___________________ Termites Carpenter ants Other Insects / Rodents_____________________________________ Pesticides/Chemicals Used____________________ Treatment Company________________ Unusual number of spider webs in basement/crawl space/building Yes No No Access Carpet or furniture treated for Mites Fleas Date/Frequency____________________ Building Information: Age:_____ Type Of Structure: 1-Fam 2-FamMultiple Condo Office 1 Story 2-Story 3 StoryHigh-Rise: Your Floor:____________ Garage: None Attached Under Detached Slab construction yes noOther_________________ Basement: None Finished Un-finished Both Crawl space: None partial fulldirt cement no access Carpeting: At:____________ Area Wall-to-wall Material: Wool Synthetic Don't know Carpeting: At:____________ Area Wall-to-wall Material: Wool Synthetic Don't know Carpeting: At:____________ Area Wall-to-wall Material: Wool Synthetic Don't know Carpeting cleaned _________ Method Used: Steam Water Dry Chemical ________________ Recent Construction: __________________________________________________________ Materials Used: (Particle board, adhesives, carpeting, painting, etc.) __________________________ Comments: ___________________________________________________________________ Room Comments Observed: Odors Mold/Mildew 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:___________________________________________________ Other Observations (Drafts, leaks, insect or rodent pests)________________________________________________________________ ________________________________________________________________________ Attic: Whole House Fan: Yes Frequency of Use:_______________ Rarely or Not Used Condensation: NoneLight Heavy No Access Roof Ventilation: None Gable-end/Roof Vent Fan Ridge Vent Soffit Vent Continuous? Obstructed? Roof Leaks: None PriorPresent Significant
Basement/Crawl Space: Water Entry and Moisture History:__________________________________________ _______________________________________________________________________ Mold/Mildew: visible @ ___________________________________________ Odors Stains Other Water Entry Signs: Partition Walls Closets Carpets/Rugs Present Windows generally shut openvaries Hours basement used/occupied per week:______ Office Exercise space Other
Chemical Storage: Pesticides/Fertilizers stored at:____________________________________________________ Cleaning/Other Chemicals stored at:________________________________________________
Other leaks / Water Entry History Notes: site drainage ice dams gutter defects plumbing leaks sewage-backup _____________________________________________________________________________ Mechanical Systems Heating Systems: Type: Furnace Hot Water Boiler Steam Stove/Fireplace Fuels: Oil Gas Electric Wood/Coal __________ Recent Problems Fuel Leak Puff-Back SpillageSoot/Dust Noises Ductwork: Last Cleaned_________________ Return Ducts at:____________________ Kick-space heaters in kitchen in bath Air Filters: Fiberglass furnace filter Fiberglass media filter Accordion Paper Filter Electronic Frequency of changing/cleaning filters:________________________
Humidifiers: (devices to add moisture to air, usually used in winter) Type: In-Room At-Furnace Leaks/Other Notes:_______________________________
Dehumidifiers: (devices to remove moisture from air, used in humid weather and/or damp locations) Present in use Last cleaned_________Coil Condition_____
Air Conditioning: Type: Central Room-Units Located at:______________________________________________ Return Air Locations: ________________________________________________________ Located near: bathroom garageutility room Duct Type: metal insulated flexiblebuilding cavities Duct Insulation: fiberglass lining? Yes No Condition: _________ Cleaned? Yes No Condensate Handling: Gravity drains Pumps Leaks? Yes No Cleaned? Yes No
Appliances Clothes Dryer at: __________________ Vented to:____________________________ Washing Machine at:_______________ Leak history___________________________ Kitchen Stove: Electric Gas ignition: Match Pilots Automatic/Electronic Refrigerator: Drip Tray missingpresent dirty Last Cleaned____________ Ice Maker Leaks? Dishwasher: Leaks Soil under unit? Other Information
Allergens/Irritants: Pets (list all)___________________________________________________________ House Plants Ficus Benjamina (ornamental fig) Bedding: Allergy control covers in use not apparentLinens washed in hot cold water. Feather pillows quilts mattresses Furniture: padded: cushions fleecy materials _________________ Fragrances Hair Spray PerfumesAir Fresheners _____________________ Candles/oil lamps burned in home Frequency_____________ Scented Candles Incense used?
Cleaning: Vacuum cleaner type: Canister Upright /HEPA filter? Brand:______________ Cleaning Service yes uses their own vacuum cleaner? Yes No
Any other comments about sources of complaint: ____________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________
Medical Consultation: Regarding these complaints) consultation has also been with Medical ProfessionalIndustrial Hygienist Home Inspector No One Else Names/Dates_________________________________________________________ __________________________________________________________________ Attach Sketchs: floor plan, bulding plan, photographs, indicating areas of complaints, suspected causes or sources of complaints. The design and content found at InspectAPedia.com® are © Copyright protected, All Rights Reserved. Contents of this website may not be copied in any form. Our main website topics listed at page left and page top provide in-depth, un-biased, expert information on building defect inspection, diagnosis, & repair. Questions & Answers regarding this articleQuestions & answers about what questions to ask when collecting indoor air quality complaints & surveys of building occupants. Ask a Question or Search InspectAPediaHTML Comment Box is loading comments...
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OTHER IAQ ISSUES: How To Find and Address Other Indoor Air or Indoor Environment Contaminants Besides MoldMold 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.
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