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Indoor Air Quality Investigation HVAC/Building Questionnaire

For office located at:

Section 1: Local management complete for referral to DHS Administrative Services Facilities Unit. Section 2: DHS Facilities coordinate completion if doing an outside referral.

Section 1 General Date Completed: Completed by: 1. Age of building? 2. Have there been remodels to this building? 3. What year did the present occupants occupy the building? 4. How many stories does the building have? 5. How many square feet of floor space is there per floor? 6. Which DHS clusters are in this building? 7. Who occupies the building besides DHS and are they experiencing similar complaints?

8. How many stories in the building? 9. What section(s) of the building are complaining about air quality? 10. List all previous types of occupancy: 11. Attach a rough sketch the location of the complainants. 12. Can the windows be opened? No Yes Please describe:

13. Please describe any complaints (e.g., lack of air, odors, etc.):

14. When did the complaints start? 15. Do staff ever use portable heaters or fans? No Yes If yes, indicate location on sketch. 16. Do any staff use portable air cleaners? No Yes If yes, indicate location on sketch and describe device. 17. Are window coverings in affected areas left open or closed?

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18. How frequently do custodians dust and do employee dust their own desks? 19. Have any tall partitions or cabinets been moved or added and if yes, what, when, and where in the office? No Yes If yes, describe: 20. What may be entering the fresh air intake on the building exterior (e.g., cigarette smoke, car exhaust, contaminants exhausting from neighboring processes)?

21. Has any new carpeting, furniture, or equipment been introduced recently? What and when? 22. Describe new cleaning products being used or products such as insecticides recently used and attach the Material Safety Data Sheet for the product. 23. Describe any construction, remodeling, or maintenance work (including painting) performed in the building. Indicate when it occurred. 24. Indicate the most recent maintenance performed on the HVAC system: 25. What are the thermostat settings: Air Heat Automatic on and off times Is fan continuously running or does it come on with the cold air or heat? 26. Have you contacted the building owner or representative? 27. What actions have been taken to try to correct the problem?

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Section 2 HVAC System (Complete if Facilities is making an outside referral.) Date Completed: Completed by: 1. Who performs maintenance of the buildings heating, cooling, and ventilation system? 2. What type of heating system is used?

3. What type of cooling system is used? 4. What type of humidification system is used?

5. How many separate systems are in use in the building? Describe each system (i.e., what floors, rooms or areas are served by each system.) System #1: System #2: System #3: System #4: System #5:

6. How is the total filtration system operated? 7. What type of filtration system is used? 8. How often is the filtration system changed/maintained?

9. When was this service last performed? 10. How much fresh air is being introduced into the ventilation system from the outside?

11. Has this ever been tested? 12. Is the fresh air introduced by natural draft or through mechanical means? 13. Where are the fresh air inlets located, and are they operating properly for each of the systems: System #1: Yes No System #2: Yes No System #3: Yes No System #4: Yes No System #5: Yes No

14. When was the HVAC system last balanced?

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15. Are there an possible sources of contamination located in the general vicinity of the system?

No Yes, if yes, describe: 16. In which direction are the prevailing winds? Are contaminants likely to be drawn into the air inlets due to prevailing winds or air inversions?

No Yes If yes, specify contaminants and the source:

17. How does exhaust air leave the building? 18. Where does the exhausted air leave the building? 19. Are there any local exhaust ventilation systems located in the building? No If yes, describe each system and the process/machine it is exhausting (include the materials use in the process/machine, where it exhausts too, and its proximity to the air inlets for building ventilation system.

Yes

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