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.
Email address *
Provide your name, e-mail address, and phone number. *
Your answer
Provide the building name. *
Your answer
Provide the space(s) of concern. *
Your answer
How long have you worked in the space? *
Your answer
How many people occupy the space? *
Your answer
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.
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. *
Your answer
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. *
Your answer
Do any of the following apply to the space? Select all that apply.
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.
Your answer
A copy of your responses will be emailed to the address you provided.
Submit
Never submit passwords through Google Forms.
reCAPTCHA
This form was created inside of University of Maryland, College Park. Report Abuse