Environmental Engineering Reference
In-Depth Information
Appendix A
NIOSH IAQ Survey Questionnaire
1. Complaints Yes ____ No ____
(If yes, please check)
____ Temperature too cold
____ Temperature too hot
____ Lack of air circulation (stuffy feeling)
____ Noticeable odors
____ Dust in air
____ Disturbing noises
____ Others (specify)
2. When do these problems occur?
____ Morning
____ Daily
____ Afternoon
____ Specific day(s) of the week
____ All day
Specify which day(s):_________
____ No noticeable trend
______________________________
3. Health Problems or Symptoms
Describe in
three words or less
each symptom or adverse health
effect you experience
more than two times
per week. (Example:
runny nose)
Symptom 1 ______________________________________________
Symptom 2 ______________________________________________
Symptom 3 ______________________________________________
Symptom 4 ______________________________________________
Symptom 5 ______________________________________________
Symptom 6 ______________________________________________
Do
all
of the above symptoms clear up within 1 hour after leaving
work? Yes ____ No ____
If no, which symptom or symptoms persist (noted at home or at
work) throughout the week?
Please indicate by drawing a circle around the symptom number
below.
Symptom: 123456
Do you have any health problems or allergies which might account
for any of the above symptoms? Yes ____ No ____
If yes, please describe.______________________________________
__________________________________________________________
__________________________________________________________
