Indoor Environmental Quality Concern – Environmental Health and Safety

Name: *

Email Address: *

Phone Number: *

Building: *

Type of concern: *

Unusual or odd odor

Concern not associated with an odd odor

Location of concern: *

Room number / area: *

Previously reported:

No

Yes (If previously reported, to whom?)Yes (If previously reported, to whom?)

With which department

Odor characterization *

Intermittent (comes and goes)

Continuous

Getting stronger

Getting weaker

Odor intensity *

Are you experiencing medical symptoms?

Describe your concern:

Are any of the following occurring in your area?

(check all that apply)

Additional comments:

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