Indoor Air Quality (IAQ) Complaint Form
This form is used to report concerns or problems related to indoor air quality in a building or workplace. Poor indoor air quality can cause discomfort, health symptoms (such as headaches, dizziness, fatigue, or allergies), or may indicate the presence of pollutants like mold, dust, chemicals, or inadequate ventilation.

By completing this form, individuals can provide detailed information about the issue, such as:

  • The location of the problem
  • The nature of the symptoms or concerns
  • When the issue occurs (time of day or specific conditions)
  • Any suspected sources (e.g., odors, dust, temperature changes)
  • How the problem is affecting people in the space
The information collected will help building management, maintenance staff, or environmental health professionals investigate and resolve the issue more effectively.

Division of Public Health: (302) 652-6880.
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Date of Complaint:  *
MM
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DD
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YYYY
Time of Complaint: *
Time
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CONTACT INFORMATION
Name & Last Name *
Phone Number *

Email Address

 *
LOCATION OF COMPLAINT
Building/Area Name *
Room/Area Affected *
NATURE OF THE COMPLAIN
Please describe the issue you're experiencing in as much detail as possible. Check all that apply: *
Required
How long has this issue been occurring? *
IMPACT ON HEALTH OR COMFORT UNTITLED TITLE
Please indicate if you or others have experienced any of the following due to IAQ issues:
PREVIOUS ACTIONS TAKEN
Have you reported this issue before? *
If yes, what actions were taken? *
ADDITIONAL INFORMATION
Please provide any other relevant information or observations.
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This form was created inside of Academia Antonia Alonso Charter School.