Indoor Air Quality Form
Please complete this form with as much detail as possible in order for ESSR personnel to better address indoor air quality concerns.
Provide your name, e-mail address, and phone number.
Provide the building name.
Provide the space(s) of concern.
How long have you worked in the space?
How many people occupy the space?
Are there windows in the space?
If yes, do the windows open?
Is any of the following equipment in the space? Select all that apply.
Window air conditioning unit
Fan coil unit
Air fresheners (plug-in or aerosol)
Is the door to the space kept mostly open or closed?
Have there been any recent floods or construction activities in or near the space? Specify below.
Are there any water-affected materials in the space? Select all that apply.
Have work orders been placed with Facilities Management specific to the issues in the space? If yes, please provide the work ticket numbers below and describe any work that has been completed.
Do any of the following apply to the space? Select all that apply.
Temperature too hot
Temperature too cold
Room feels stuffy
Dust/dirt on air vents
Are you or others in the space experiencing any health effects? If yes, ESSR will contact you for more information.
Please provide any further information that you feel would be helpful to ESSR.
A copy of your responses will be emailed to the address you provided.
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This form was created inside of University of Maryland, College Park.