| Indoor Air Quality
Interview Form
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| 1. Building:
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2. Room Number:
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| 3. Occupant Name (Last, First,
Middle Initial):
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| 4a. Completed By (Last, First,
Middle Initial:
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| 4b. Title:
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4c. Date:
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| Symptom Patterns
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| 5. What kind of symptoms or
discomfort are you experiencing?
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| 5b. Are you aware of other people
with similar symptoms or concerns? Yes
No
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5c. If "Yes" to 5b, what are
their names and locations?
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6. Do you have any health
conditions that may make you particularly susceptible to environmental
problems?
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| Timing Patterns
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7. When did your symptoms start?
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8. Where are they generally
worst?
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9. Do they go away? If so, when?
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10. Have you noticed any other
events (such as weather events, temperature or humidity changes, or activities
in the building) that tend to occur around the same time as your symptoms?
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| Spatial Concerns
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11. Where are you when you
experience symptoms or discomfort?
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| Additional Information
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12. Do you have any observations
about building conditions that might need attention or might help explain your
symptoms (e.g., temperature, humidity, drafts, stagnant air, odors)?
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13. Have you sought medical
attention for your symptoms?
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| 13b. Have you obtained relief as
a result of this medical attention? Yes
No
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14. Any other comments:
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