YESHIVA UNIVERSITY
 

DEPARTMENT of ENVIRONMENTAL HEALTH and SAFETY

Phone: 212-923-0784                                                                                                                                                                        Fax: 212-923-1398

INDOOR AIR QUALITY QUESTIONNAIRE

NOTE: The On-line Form only works with Internet Explorer. It does not work with Netscape.

Name:      Phone Number:  

Location (Office Address and Room No.):  

Department:        Date:    

Supervisor's Name:     Phone Number: 

Location (Office Address and Room No.):  

Do you have any complaints? Yes  No - If yes, please check from the following:

Temperature too cold    Temperature too hot Lack of air circulation (stuffy feeling)

Noticeable odors           Dust in the air          Disturbing noise

Other, please specify:

What kind of symptoms of discomforts are you experiencing?


When do these problems occur?

Morning    Afternoon    All Day    Daily    No Noticeable Trend

Specific day(s) of the week - which days?


 

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