Indoor Air Quality Complaint

This is to document in real time the problem you are experiencing. The information will be forwarded to a specialist in the Safety, Health and Environmental Affairs Department.

Employee/Student Name: (For SHEA follow up, a name is required.)

Telephone:

Location of Incident: (Room/Bldg)

Date of Occurrence:

Time and Duration:

Are other persons affected? If so, they must also complete this incident report form.

Please describe the occurrence:

Any unusual odors?

Do you know of anything that may have contributed to this incident?

Any unusual activities in the area?

Have you reported this situation to your supervisor?Yes No

Name of your supervisor:

Have you reported this problem to the Physical Plant Department? (277-6467)Yes No

Have you reported your exposure to Employee/Occupational Health Service? (272-8043)Yes No

Other comments?