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EPA Building Air Quality Guide-1991

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Occupant Interview Page 1 of 2 Indoor Air Quality Forms 185 Building Name: ____________________________________________________ File Number: _______________________ Address: ____________________________________________________________________________________________ Occupant Name: ______________________________________ Work Location: __________________________________ Completed by:_____________________________________ Title: ________________________ Date:_______________ Sections 4 discusses collecting and interpreting information from occupants. SYMPTOM PATTERNS What kind of symptoms or discomfort are you experiencing? Are you aware of other people with similar symptoms or concerns? Yes ___________ No ___________ If so, what are their names and locations? __________________________________________________________________ Do you have any health conditions that may make you particularly susceptible to environmental problems? ❑ contact lenses ❑ chronic cardiovascular disease ❑ undergoing chemotherapy or radiation therapy ❑ allergies ❑ chronic respiratory disease ❑ immune system suppressed by disease or other causes ❑ chronic neurological problems TIMING PATTERNS When did your symptoms start? When are they generally worst? Do they go away? If so, when? Have you noticed any other events (such as weather events, temperature or humidity changes, or activities in the building) that tend to occur around the same time as your symptoms?

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