Allergen/Toxic Mold Indoor Air Quality Investigation Questionnaire

  • - CONTENTS: Building indoor air quality questionnaire form © Copyright 2010
  • Building-Related Health or IAQ Complaint recording & diagnostic checklist: Mold, odor, allergy, other complaints
  • POST a QUESTION or READ FAQs about what questions to ask when collecting indoor air quality complaints & surveys of building occupants

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:      _____________________________________


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

odors/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 ______________________________________




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-Fam  2-FamMultiple   Condo  Office

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

Garage: None Attached   Under   Detached     Slab construction yes noOther_________________

Basement: None Finished    Un-finished    Both            Crawl space: None  partial  fulldirt  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)________________________________________________________________



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    openvaries

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


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   SpillageSoot/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   Last cleaned_________Coil Condition_____


Air Conditioning:

Type: Central  Room-Units   Located at:______________________________________________

Return Air Locations: ________________________________________________________

Located near:  bathroom   garageutility room               Duct Type:  metal  insulated  flexiblebuilding cavities

Duct Insulation: fiberglass lining? Yes  No          Condition: _________    Cleaned? Yes  No

Condensate Handling:  Gravity drains    Pumps       Leaks? Yes  No              CleanedYes  No



Clothes Dryer at: __________________ Vented to:____________________________

Washing Machine at:_______________ Leak history___________________________

Kitchen Stove: Electric Gas          ignition: Match Pilots Automatic/Electronic

Refrigerator: Drip Tray  missingpresent  dirty  Last Cleaned____________ Ice Maker Leaks?

Dishwasher: Leaks   Soil under unit?

Other Information



Pets (list all)___________________________________________________________

House Plants Ficus Benjamina (ornamental fig)

Bedding: Allergy control covers in use  not apparentLinens  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?



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



Attach Sketchs: floor plan, building plan, photographs, indicating areas of complaints, suspected causes or sources of complaints.

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