ETFO-UCL IAQ Survey for Members

Indoor Air Quality Survey

This optional survey is being provided to ETFO members at your school site to help us learn more about Indoor Air Quality (IAQ) concerns through your personal experiences and knowledge of the work environment. If you choose to complete this survey, your identity and individual responses will be kept confidential. Please complete this survey as soon as possible. ETFO will prepare a summary report about IAQ concerns at the school as a whole and present this report to your principal and the school board. No individuals wil be identified in the survey report. All respondents will receive a copy of the report.

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* 1. Name of school:

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* 2. How long have you worked at this worksite?

less than 1 year

1-2 years

3-5 years

5-10 years

10-15 years

more than 15 years

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* 3. How long have you worked at this worksite?

less than 1 year

1-2 years

3-5 years

5-10 years

10-15 years

more than 15 years

For questions matrix, in the last year, did you experience any of the following health symptoms that lasted two days or more?

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* 4. Headache

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* 5. Nausea

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* 6. Dizziness

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* 7. Tiredness/Fatigue

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* 8. Eye/Nose/Throat Irritation

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* 9. Breathing Problems

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* 10. Stuffy or Runny Nose

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* 11. Sinus Congestion

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* 12. Coughing

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* 13. Sneezing

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* 14. Wheezing

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* 15. Shortness of Breath

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* 16. Blurred Vision

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* 17. Difficulty Concentrating

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* 18. Other

If you answered NO to all of the above questions, please stop here. If you answered YES to any of the questions, please continue.

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* 19. In the last year, did you experience any of the following health symptoms that lasted two days or more?

	Frequently	Sometimes	Occasionally	Never
Headache	Headache Frequently	Headache Sometimes	Headache Occasionally	Headache Never
Nausea	Nausea Frequently	Nausea Sometimes	Nausea Occasionally	Nausea Never
Dizziness	Dizziness Frequently	Dizziness Sometimes	Dizziness Occasionally	Dizziness Never
Tiredness and/or fatigue	Tiredness and/or fatigue Frequently	Tiredness and/or fatigue Sometimes	Tiredness and/or fatigue Occasionally	Tiredness and/or fatigue Never
Irritation of eyes, nose, and/or throat	Irritation of eyes, nose, and/or throat Frequently	Irritation of eyes, nose, and/or throat Sometimes	Irritation of eyes, nose, and/or throat Occasionally	Irritation of eyes, nose, and/or throat Never
Breathing problems	Breathing problems Frequently	Breathing problems Sometimes	Breathing problems Occasionally	Breathing problems Never
Stuffy and/or runny nose	Stuffy and/or runny nose Frequently	Stuffy and/or runny nose Sometimes	Stuffy and/or runny nose Occasionally	Stuffy and/or runny nose Never
Sinus congestion	Sinus congestion Frequently	Sinus congestion Sometimes	Sinus congestion Occasionally	Sinus congestion Never
Coughing	Coughing Frequently	Coughing Sometimes	Coughing Occasionally	Coughing Never
Sneezing	Sneezing Frequently	Sneezing Sometimes	Sneezing Occasionally	Sneezing Never
Wheezing	Wheezing Frequently	Wheezing Sometimes	Wheezing Occasionally	Wheezing Never
Shortness of breath	Shortness of breath Frequently	Shortness of breath Sometimes	Shortness of breath Occasionally	Shortness of breath Never
Blurred vision	Blurred vision Frequently	Blurred vision Sometimes	Blurred vision Occasionally	Blurred vision Never
Difficulty concentrating	Difficulty concentrating Frequently	Difficulty concentrating Sometimes	Difficulty concentrating Occasionally	Difficulty concentrating Never

Other (please specify)