Air Quality Survey

Each day, we breathe 35 lbs of air. Why not make sure the air you breathe is healthy and safe.

Name *

First

Last

Address

Address Line 1

City

AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingState

Zip Code

Email *

Phone

Indicate if you frequently have any of the following complaints concerning the indoor air quality of your building.

• Temperature too hot/cold
• Stuffy air
• Moldy odors
• Poor lighting
• Dusty
• Noisy
• Too dry
• Too humid or too much moisture
• Drafty
• Vibration
• Crowded work area/health concerns

Indicate if any of the following apply to you.

• Wear contact lenses
• Operate video display terminals at least one hour/average day
• Use any chemical substance such as cleaners
• Use tobacco products

Since spending time in the building, have you experienced:

• Allergies
• Asthma
• Sinusitis
• Laryngitis
• Other respiratory conditions

Have you noticed any of the following after spending time in the building?

• Frequent cough or wheezing
• Fatigue/Drowsiness
• Burning, itchy or watery eyes
• Sneezing attacks or nasal congestion
• Sore throat or hoarse voice
• Headaches or migraines
• Feeling like you’re “always” sick
• “Brain fog”

Do you rely on any of the following to help you through the times you feel poorly?

• Pain relievers
• Decongestants
• Antihistimines

Submit