InspectAPedia®   -   Search InspectApedia

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.

InspectAPedia tolerates no conflicts of interest. We have no relationship with advertisers, products, or services discussed at this website.

- Daniel Friedman, Publisher/Editor/Author - See WHO ARE WE?

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
without permission. Contact us to suggest changes/additions to the form. © 2012 - 1985 Daniel Friedman, All Rights Reserved.

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.

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 top or at the MORE READING links at the bottom of this article provide in-depth, un-biased, expert information on building defect inspection, diagnosis, & repair.


...

Continue reading at SICK BUILDING SYNDROME SBS CHECKLISTS or select a topic from the closely-related articles below, or see the complete ARTICLE INDEX.

Or see these

Sick Building Syndrome Articles

Suggested citation for this web page

SICK HOUSE IAQ QUESTIONNAIRE at InspectApedia.com - online encyclopedia of building & environmental inspection, testing, diagnosis, repair, & problem prevention advice.


Or see this

INDEX to RELATED ARTICLES: ARTICLE INDEX to BUILDING ENVIRONMENT

Or use the SEARCH BOX found below to Ask a Question or Search InspectApedia

Or see

INDEX to RELATED ARTICLES: ARTICLE INDEX to BUILDING INDOOR AIR QUALITY IAQ

Or use the SEARCH BOX found below to Ask a Question or Search InspectApedia

Or see

INDEX to RELATED ARTICLES: ARTICLE INDEX to MOLD CONTAMINATION & REMEDIATION

Or use the SEARCH BOX found below to Ask a Question or Search InspectApedia

Ask a Question or Search InspectApedia

Questions & answers or comments about finding, using, diagnosing, repairing, or replacing water pressure gauges on private well systems.

Try the search box just below, or if you prefer, post a question or comment in the Comments box below and we will respond promptly.

Search the InspectApedia website

Note: appearance of your Comment below may be delayed: if your comment contains an image, photograph, web link, or text that looks to the software as if it might be a web link, your posting will appear after it has been approved by a moderator. Apologies for the delay.

Only one image can be added per comment but you can post as many comments, and therefore images, as you like.
You will not receive a notification when a response to your question has been posted.
Please bookmark this page to make it easy for you to check back for our response.
Our Comment Box is provided by Countable Web Productions countable.ca

Comment Form is loading comments...

Citations & References

In addition to any citations in the article above, a full list is available on request.


ADVERTISEMENT