Indoor Air Quality Questionnaire

This questionnaire concerns your indoor climate and possible symptoms you may be experiencing.

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* 1. Please supply:

Name (optional)

School District

Building

Classroom number (optional)

Occupation

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* 2. How old are you?

16-24 yrs.

25-39 yrs.

40-55 yrs.

55+ yrs.

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* 3. You are

Male

Female

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* 4. Do you smoke?

Yes

No

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* 5. Where do you most commonly work?

Open Area

Classroom

Other (please specify)

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* 6. Please select the department and location which best describes where you work in the building.

Basement

First Floor

Second Floor

Third Floor

Office

Grounds

Department

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* 7. How long have you worked in this particular building?
Please enter number of years:

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* 8. What is the average hours of week you spend in the building?
Please enter number of hours:

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* 9. How many hours per week do you spend working on a computer?
Please enter number of hours per week on computer:

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* 10. Work Environment

Have you been bothered during the last three months by any of the following factors at your workplace?

	Yes, often (every week)	Yes, sometimes	No , never
Draft	Draft Yes, often (every week)	Draft Yes, sometimes	Draft No , never
Room temperature too high.	Room temperature too high. Yes, often (every week)	Room temperature too high. Yes, sometimes	Room temperature too high. No , never
Varying room temperature.	Varying room temperature. Yes, often (every week)	Varying room temperature. Yes, sometimes	Varying room temperature. No , never
Room temperature too low	Room temperature too low Yes, often (every week)	Room temperature too low Yes, sometimes	Room temperature too low No , never
Stuffy “bad” air.	Stuffy “bad” air. Yes, often (every week)	Stuffy “bad” air. Yes, sometimes	Stuffy “bad” air. No , never
Dry air.	Dry air. Yes, often (every week)	Dry air. Yes, sometimes	Dry air. No , never
Unpleasant odor.	Unpleasant odor. Yes, often (every week)	Unpleasant odor. Yes, sometimes	Unpleasant odor. No , never
Static electricity, often causing shocks.	Static electricity, often causing shocks. Yes, often (every week)	Static electricity, often causing shocks. Yes, sometimes	Static electricity, often causing shocks. No , never
Second-hand smoke.	Second-hand smoke. Yes, often (every week)	Second-hand smoke. Yes, sometimes	Second-hand smoke. No , never
Noise.	Noise. Yes, often (every week)	Noise. Yes, sometimes	Noise. No , never
Light that is dim or causes glare and/or reflections.	Light that is dim or causes glare and/or reflections. Yes, often (every week)	Light that is dim or causes glare and/or reflections. Yes, sometimes	Light that is dim or causes glare and/or reflections. No , never
Dust and dirt.	Dust and dirt. Yes, often (every week)	Dust and dirt. Yes, sometimes	Dust and dirt. No , never

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* 11. Work Conditions

	Yes, often (every week)	Yes, sometimes	No, seldom	No , never
Do you regard your work as interesting and stimulating?	Do you regard your work as interesting and stimulating? Yes, often (every week)	Do you regard your work as interesting and stimulating? Yes, sometimes	Do you regard your work as interesting and stimulating? No, seldom	Do you regard your work as interesting and stimulating? No , never
Do you have too much work to do?	Do you have too much work to do? Yes, often (every week)	Do you have too much work to do? Yes, sometimes	Do you have too much work to do? No, seldom	Do you have too much work to do? No , never
Do you have any opportunity to influence your working conditions?	Do you have any opportunity to influence your working conditions? Yes, often (every week)	Do you have any opportunity to influence your working conditions? Yes, sometimes	Do you have any opportunity to influence your working conditions? No, seldom	Do you have any opportunity to influence your working conditions? No , never
Do your fellow workers help you with problems you have in your work?	Do your fellow workers help you with problems you have in your work? Yes, often (every week)	Do your fellow workers help you with problems you have in your work? Yes, sometimes	Do your fellow workers help you with problems you have in your work? No, seldom	Do your fellow workers help you with problems you have in your work? No , never

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* 12. Past/Present Diseases Symptoms

	Yes	No
Have you ever had asthma problems?	Have you ever had asthma problems? Yes	Have you ever had asthma problems? No
Have you ever suffered from hayfever?	Have you ever suffered from hayfever? Yes	Have you ever suffered from hayfever? No
Have you ever suffered from eczema?	Have you ever suffered from eczema? Yes	Have you ever suffered from eczema? No
Does anybody else in your family suffer from allergies? (e.g. asthma, hayfever, eczema)	Does anybody else in your family suffer from allergies? (e.g. asthma, hayfever, eczema) Yes	Does anybody else in your family suffer from allergies? (e.g. asthma, hayfever, eczema) No

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* 13. During the last three months, have you had any of the following symptoms? If YES, does the symptom improve when you are away from work?

	Yes, often (every week)	Yes, sometimes	No , never	Yes, this symptom improves away from work	No improvement away from work
Fatigue	Fatigue Yes, often (every week)	Fatigue Yes, sometimes	Fatigue No , never	Fatigue Yes, this symptom improves away from work	Fatigue No improvement away from work
Feeling heavy-headed	Feeling heavy-headed Yes, often (every week)	Feeling heavy-headed Yes, sometimes	Feeling heavy-headed No , never	Feeling heavy-headed Yes, this symptom improves away from work	Feeling heavy-headed No improvement away from work
Headache	Headache Yes, often (every week)	Headache Yes, sometimes	Headache No , never	Headache Yes, this symptom improves away from work	Headache No improvement away from work
Nausea/dizziness	Nausea/dizziness Yes, often (every week)	Nausea/dizziness Yes, sometimes	Nausea/dizziness No , never	Nausea/dizziness Yes, this symptom improves away from work	Nausea/dizziness No improvement away from work
Difficulties concentrating	Difficulties concentrating Yes, often (every week)	Difficulties concentrating Yes, sometimes	Difficulties concentrating No , never	Difficulties concentrating Yes, this symptom improves away from work	Difficulties concentrating No improvement away from work
Itching, burning or irritation of the eyes	Itching, burning or irritation of the eyes Yes, often (every week)	Itching, burning or irritation of the eyes Yes, sometimes	Itching, burning or irritation of the eyes No , never	Itching, burning or irritation of the eyes Yes, this symptom improves away from work	Itching, burning or irritation of the eyes No improvement away from work
Irritated, stuffy or runny nose	Irritated, stuffy or runny nose Yes, often (every week)	Irritated, stuffy or runny nose Yes, sometimes	Irritated, stuffy or runny nose No , never	Irritated, stuffy or runny nose Yes, this symptom improves away from work	Irritated, stuffy or runny nose No improvement away from work
Hoarse, dry throat	Hoarse, dry throat Yes, often (every week)	Hoarse, dry throat Yes, sometimes	Hoarse, dry throat No , never	Hoarse, dry throat Yes, this symptom improves away from work	Hoarse, dry throat No improvement away from work
Cough	Cough Yes, often (every week)	Cough Yes, sometimes	Cough No , never	Cough Yes, this symptom improves away from work	Cough No improvement away from work
Dry or flushed facial skin	Dry or flushed facial skin Yes, often (every week)	Dry or flushed facial skin Yes, sometimes	Dry or flushed facial skin No , never	Dry or flushed facial skin Yes, this symptom improves away from work	Dry or flushed facial skin No improvement away from work
Scaling/itching scalp or ears	Scaling/itching scalp or ears Yes, often (every week)	Scaling/itching scalp or ears Yes, sometimes	Scaling/itching scalp or ears No , never	Scaling/itching scalp or ears Yes, this symptom improves away from work	Scaling/itching scalp or ears No improvement away from work
Hands dry, itching, red skin	Hands dry, itching, red skin Yes, often (every week)	Hands dry, itching, red skin Yes, sometimes	Hands dry, itching, red skin No , never	Hands dry, itching, red skin Yes, this symptom improves away from work	Hands dry, itching, red skin No improvement away from work

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* 14. Please list any additional symptom(s) you have experiences in the last three months, how often the symptom(s) occur and if the symptom(s) improves when you are away from work.

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* 15. Additional comments