CONTACT
INFORMATION
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Home Phone:
Area Code First
Alternate Phone:
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Best time to call:
Morning
Afternoon
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Building Type: Residential
Commercial
Number of Occupants:
SURVEY QUESTIONS
1. On a scale of
1 – 10 (1=poor 10=excellent) how would you rate the indoor
air quality of your home or building?
Choose
1
2
3
4
5
6
7
8
9
10
2. Are there any
areas within your home that have odors, dampness,
water issues or mold?
Choose
YES
NO
3. Do you believe
any of the following areas within your home have IAQ
problems (check as many as apply)?
Bedroom
Living
Room
Dining
Room
Hallways
Bathroom
Playroom
Basement
Den
Other
Rooms
4. Do you have
any pets/animals?
Choose
YES
NO
5. Do you have
carpeting in: (check as many as apply)?
Bedroom
Living
Room
Dining
Room
Hallways
Bathroom
Playroom
Basement
Den
Other
Rooms
6. Are any of the
inhabitants experiencing itchy skin, watery eyes,
runny noses, coughing, sneezing, allergies, asthma or lung
problems?
Choose
YES
NO
7. Do you believe
that poor air quality might be contributing to either
sickness or allergic reactions within your home or
building?
Choose
YES
NO
8. Do you
want to improve the Indoor Air Quality within your
home?
Choose
YES
NO
If
you rated your home between a one to seven, or are
experiencing health problems you probably want to
continue gathering data. We can assist you in
assessing your home by providing you with an
assessment kit that includes two samples (additional
samples could be included). Areas assessed will
include heating/cooling systems, general living areas,
and moisture prone areas. Surface samples will be sent
to a laboratory for analysis quantifying common indoor
contaminants within your home.
9. Do you
want your home assessed, and samples taken for
laboratory analysis? The total cost for the assessment
and sample package is $149.00.
Choose
YES
NO