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Photograph of toxic gas testing equipment in use (C) Daniel FriedmanSick Building, SBS Questionnaire

Allergen/Toxic Mold Indoor Air Quality Investigation Questionnaire

  • POST a QUESTION or COMMENT about what questions to ask when collecting indoor air quality complaints & surveys of building occupants

How to find the cause of indoor air quality or sick-building syndrome (SBS) problems in buildings:

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

Email:      _____________________________________

Website: InspectAPedia.com

Write-in or circle information below as appropriate. Copying of this form is permitted as needed provided no changes are made to this document
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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

o dors/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 Lawn Pest Treatment History: 

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 Office

                1 Story   2-Story   3 StoryHigh-Rise: Your Floor :____________

Garage: None Attached   Under   Detached     Slab construction yes no Other_________________

Basement: None Finished    Un-finished    Both             Crawl space: None  partial   full dirt  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    open   varies 

Hours basement used/occupied per week :_ _____ Office   Exercise space   Other

o:p> 

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   Spillage Soot/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   L ast cleaned_________Coil Condition_____

 

Air Conditioning:

Type: Central  Room -Units   Located at:______________________________________________

Return Air Locations: ________________________________________________________

Located near:  bathroom   garage utility room                Duct Type:   metal  insulated  flexible building 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  missing present  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 apparent Linens  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, building plan, photographs, indicating areas of complaints, suspected causes or sources of complaints.

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