INDOOR AIR QUALITY EVALUATION CHECKLIST

 
INDOOR AIR QUALITY EVALUATION CHECKLIST

Copyright 2008, W. E. Kuriger, All Rights Reserved

No part of this document may be copied by any means. The information you provide will be used to identify possible sources of air pollutants in your home or office. Your answers will be the basis for recommendations we make to help you correct indoor air pollution problems. Answer all questions in each section as accurately as possible. It's simple!

 

Fill in the check box or the text box were applicable.

 

Preliminary Data:

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YOUR NAME:

BUSINESS NAME (if applicable):

ADDRESS:

ADDRESS:

CITY: STATE: AL- ALABAMA AK - ALASKA AS - AMERICAN SAMOA AZ - ARIZONA AR - ARKANSAS CA - CALIFORNIA CO - COLORADO CT - CONNECTICUT DE - DELAWARE DC - DISTRICT OF COLUMBIA FM - FEDERATED STATES OF MICRONESIA FL - FLORIDA GA - GEORGIA GU - GUAM HI - HAWAII ID - IDAHO IL - ILLINOIS IN - INDIANA IA - IOWA KS - KANSAS KY - KENTUCKY LA - LOUISIANA ME - MAINE MH - MARSHALL ISLANDS MD - MARYLAND MA - MASSACHUSETTS MI - MICHIGAN MN - MINNESOTA MS - MISSISSIPPI MO - MISSOURI MT - MONTANA NE - NEBRASKA NV - NEVADA NH - NEW HAMPSHIRE NJ - NEW JERSEY NM - NEW MEXICO NY - NEW YORK NC - NORTH CAROLINA ND - NORTH DAKOTA MP - NORTHERN MARIANA ISLANDS OH - OHIO OK - OKLAHOMA OR - OREGON PW - PALAU PA - PENNSYLVANIA PR - PUERTO RICO RI - RHODE ISLAND SC - SOUTH CAROLINA SD - SOUTH DAKOTA TN - TENNESSEE TX - TEXAS UT - UTAH VT - VERMONT VI - VIRGIN ISLANDS VA - VIRGINIA WA - WASHINGTON WV - WEST VIRGINIA WI - WISCONSIN WY - WYOMING AE - Armed Forces Africa AA - Armed Forces Americas (except Canada) AE - Armed Forces Europe AE - Armed Forces Middle East AP - Armed Forces Pacific ZIP CODE:

EMAIL ADDRESS:

TELEPHONE NUMBER:

TYPE OF CREDIT CARD:  American Express   Visa   Master Card   Discover

CREDIT CARD NUMBER:     EXPIRATION DATE:

TYPE OF BUILDING: SINGLE FAMILY HOUSE   MULTI-FAMILY   HOUSE WITH APARTMENTS  WE ARE ON THE FLOOR   OFFICE   SCHOOL OTHER    SIZE: square feet (e.g. small house - 1,000 square feet, medium house - 2,000 square feet, large house - 3,500 square feet and up)

HOW OLD IS THE BUILDING?

HOW MANY FLOORS (STORIES)?      NUMBER OF ROOMS:      YEAR CONSTRUCTED:     NUMBER OF CHILDREN PRESENT:      NUMBER OF ADULTS PRESENT:         NUMBER OF PETS PRESENT:      DOGS:      CATS:      BIRDS:     OTHER:

IF AN OFFICE OR BUSINESS - WHAT TYPE?

FUELS USED FOR FURNACES, AIR CONDITIONING UNITS, APPLIANCES:           NATURAL GAS    KEROSINE   OIL   OTHER

TYPE OF HEAT:  FORCED HOT WATER   FORCED HOT AIR   HEAT EXCHANGER   STEAM   OTHER

TYPE OF VENTILATION:  OPEN WINDOWS   HEATING-VENTILATION-AIRCONDITIONING (HVAC) SYSTEM   OPEN WINDOWS   OTHER - Describe:

DO YOU HAVE A DRINKING WATER WELL?   Yes   No

DO YOU HAVE A    SEPTIC SYSTEM   CESSPOOL?

DESCRIBE ANY INDOOR AIR PROBLEMS THAT YOU NOTICE AT THE PRESENT TIME: 

DESCRIBE ANY SYMPTOMS (e.g. headaches, difficulty in breathing) THAT   ADULTS   CHILDREN, BOTH HAVE WHILE IN THE BUILDING.

DO THE SYMPTOMS GO AWAY WHEN YOU AND/OR OTHERS LEAVE THE BUILDING? Yes   No

DOES EVERYONE IN THE HOME OR OFFICE HAVE SIMILAR SYMPTOMS?  Yes   No

DOES ANYONE HAVE ASTHMA   ALLERGIES?   Yes  No

DOES EVERYONE IN THE BUILDING HAVE ASTHMA   ALLERGIES?   Yes  No

BUILDING AND NEIGHBORHOOD HAS ANY WATER DAMAGE OR STAINING FROM LEAKING PIPES, FLOODING, SEWER BACKUP, RAIN, CONDENSATION, LEAKING ROOFS, OR SPRINKLER DISCHARGE OCCURRED IN THE BUILDING?   Yes  No

ARE THERE ANY LEAKS AT THE PRESENT TIME?   Yes  No

WHAT TYPE OF NEIGHBORHOOD IS THE BUILDING IN?   RESIDENTIAL   COMMERCIAL   INDUSTRIAL

IS THERE A GASOLINE STATION,   AUTOMOBILE REPAIR FACILITY,   DRY CLEANERS,   OIL OR CHEMICAL DEPOT,   INDUSTRIAL BUILDING,   GAS UTILITY,  WASTE WATER TREATMENT PLANT OR   LANDFILL/RECYCLING CENTER NEXT TO YOUR BUILDING OR   WITHIN 500 FEET?   OTHER:

WAS THERE EVER A FIRE IN THE BUILDING?   Yes  No

IS A GARAGE PRESENT?   ATTACHED TO THE HOUSE   SEPARATE FROM THE HOUSE?

BUILDING ENVIRONMENT: 

DO YOU LIVE IN A MODERN, INSULATED HOME WITH ENERGY EFFICIENT WINDOWS, DOORS, APPLIANCES AND HEATING SYSTEM?   Yes  No

WHAT CONSTRUCTION MATERIALS ARE PRESENT IN THE BUILDING?   PARTICLE BOARD   PLYWOOD   VINYL SIDING   WOOD SIDING     STUCCO OR CONCRETE WALLS

ESTIMATE THE AMOUNT OF FLOOR AND STAIR SURFACES THAT ARE COVERED WITH CARPET:   100%   75%   50%   25%   OR LESS.

DO YOU KNOW IF THERE IS ADEQUATE FRESH AIR FOR EFFICIENT COMBUSTION OF YOUR FUEL-BURNING APPLIANCES?   Yes  No

- Although insulation reduces heat loss in your home, fuel-burning appliances need the proper amount of oxygen to operate efficiently. Proper ventilation is always important in your home. Leave windows open slightly or adjust the HVAC system to allow sufficient fresh air for efficient combustion. Saving a life is more important than saving a few dollars on your fuel bill.

IS THERE A DEDICATED SOURCE OF FRESH AIR FOR THE FURNACE?   Yes  No

DO YOU SMOKE INDOORS?   Yes  No

HOW MANY PEOPLE SMOKE IN THE HOUSE OR OFFICE?

DO YOU AND OTHERS FEEL CONGESTED, STUFFY, TIRED OR IRRITABLE WHEN A NUMBER OF PEOPLE ARE IN YOUR HOME OR OFFICE?   Yes  No

DOES THE BUILDING HAVE A "HOUSETOSIS"-LIKE ODOR?   Yes  No

INSULATION:   Yes  No     IF NO, GO ON TO NEXT SECTION (BASEMENT)

>IS THERE ANY   FIBERGLASS,   ROCKWOOL,   PAPER (cellulose),   ASBESTOS or    OTHER INSULATION, WITHIN THE HOUSE OR BASEMENT IN   WALLS,   CEILINGS,  WRAPPED AROUND PIPES AT THE  FURNACE OR   OTHER APPLIANCES?

ARE THERE ANY OTHER SOURCES OF ASBESTOS IN THE BUILDING?   Yes  No   EXPLAIN

BASEMENT:   Yes  No     IF NO, GO ON TO NEXT SECTION (FURNACES AND CHIMNEYS)

IS THERE A BASEMENT IN THE BUILDING?   Yes  No

IS THE BASEMENT FLOOR COVERED WITH   CONCRETE   TILE   WOOD   OTHER MATERIALS, OR
IS THE FLOOR    EXPOSED SOIL WITHOUT A COVERING?

IS THERE ANY ROCK PRESENT IN THE BASEMENT OR VISIBLE AT THE SURFACE OUTSIDE OF THE BUILDING?    Yes  No

DOES THE BASEMENT CONTAIN ANY FINISHED ROOMS WITH SHEETROCK OR PLASTER WALLS?   Yes  No

ARE THERE ANY DARK BLACK/GREEN SLIMY STAINS OR OTHER STAINS ON THE FINISHED WALLS?   Yes  No

DOES WATER ENTER THE BASEMENT DURING WET PERIODS?   Yes No

 

IS THERE A SUMP PUMP(S) IN THE BASEMENT TO PUMP WATER?   Yes 

OR ARE WATER LEAKS COMMON IN THE SPRING No

OR OTHER SEASONS?   Yes  No

IS THE BASEMENT AND HOUSE OVER AN   OLD MINE,   OTHER EXCAVATION,   IN A DEEP VALLEY?

FURNACES AND CHIMNEYS:  Yes  No   IF NO, GO ON TO NEXT SECTION (FUEL-FIRED APPLIANCES)

ARE FUEL-BURNING FURNACES IN GOOD REPAIR?   Yes  No

IS THERE SOOT OR SMOKE AROUND THE FURNACE?   Yes  No

ARE THERE ANY   LOOSE,   CRACKED,    DISCONNECTED,   VENT OR   CHIMNEY
CONNECTIONS?   Yes  No

IS ANY CHIMNEY BLOCKED BY BIRD NESTS, LEAVES, SOOT, CREOSOTE, LOOSE MORTAR, BRICKS OR TRASH?   Yes  No

ARE THERE ANY PROBLEMS THAT COULD INDICATE IMPROPER FURNACE OPERATION SUCH AS   INABILITY OF FURNACE TO HEAT HOUSE PROPERLY, OR   A FURNACE THAT CONSTANTLY RUNS?    Yes  No

HAVE YOU NOTICED ANY ODOR OF SMOKE OR VISIBLE BACKDRAFTS FROM THE FURNANCE OR CHIMNEY?    Yes  No

DO YOU HAVE MORE THAN TWO APPLIANCES CONNECTED TO ONE CHIMNEY FLUE, e.g. A WOOD STOVE AND THE FURNACE AND A HOT WATER HEATER?    Yes  No

DOES THE FLUE LINER OF YOUR CHIMNEY EXTEND TWO FEET ABOVE THE RIDGE (TOP) OF YOUR ROOF? Yes  No

IF YOU HAVE A FLAT OR LOW-PITCHED ROOF, DOES THE FLUE LINER EXTEND AT LEAST THREE FEET ABOVE THE HIGHEST POINT OF THE ROOF? Yes  No

IF YOU HAVE MULTIPLE FLUES IN A CHIMNEY, ARE THE FLUE LINERS AT DIFFERENT HEIGHTS TO AVOID
DOWNDRAFTS?    Yes  No

> FUEL FIRED APPLIANCES:   Yes  No   IF NO, GO ON TO NEXT SECTION (FIREPLACES, WOOD STOVES, COAL STOVES & CHARCOAL GRILLS)

ARE FUEL-FIRED (e.g. natural gas, oil-fired) APPLIANCES INSTALLED ACCORDING TO MANUFACTURER'S
INSTRUCTIONS AND LOCAL BUILDING CODES?    Yes  No

IF YOU HAVE A NATURAL GAS FIRED STOVE OR OVEN IS THERE AN EXHAUST FAN THAT IS VENTED TO THE OUTDOORS CONNECTED OR NEAR THE APPLIANCE?    Yes  No

DOES THE EXHAUST FAN GO ON WHENEVER THE GAS STOVE IS OPERATED? Yes  No

DO YOU USE THE GAS KITCHEN STOVE FOR HEATING?    Yes  No   Note: this should never be done!

DOES THE EXHAUST PIPE OF YOUR GAS CLOTHES DRYER CONTAIN A BUILD-UP OF LINT?   Yes  No

IS THE DRYER VENT PIPE BLOCKED?    Yes  No

IS THE VENT PIPE CONNECTED TO THE OUTDOORS?    Yes  No

DO YOU CLEAN THE LINT FILTER OF YOUR GAS CLOTHES DRYER AFTER EVERY LOAD OF LAUNDRY? Yes  No

FIREPLACES, WOOD STOVES, COAL STOVES & CHARCOAL GRILLS:   Yes  No   IF NO, GO ON TO NEXT SECTION (SPACE HEATERS)

DO YOU OPEN THE FLUE DAMPER WHENEVER THE FIREPLACE, WOOD OR COAL STOVE IS IN USE?
Yes  No

DO YOU KEEP THE FIREPLACE OR STOVE FLUE DAMPER OPEN UNTIL THE FIRE IS COMPLETELY OUT? Yes  No

DO ALL THE DOORS OF YOUR WOOD OR COAL STOVE FIT TIGHTLY? Yes  No

>A good draft will carry smoke up the chimney. A poor draft and loose fitting doors or an open damper can result
in smoke and CO coming into the house when there is a poor draft. The size of the flue, available fresh air, the height above the roof, the number of appliances connected to the flue and intensity of the fire all play a role in determining if exhaust smoke goes up the chimney correctly. Have the chimney inspected by a mason, chimney cleaner or other expert.

HAVE YOU NOTICED ANY ODOR OF SMOKE OR VISIBLE BACKDRAFTS FROM THE FIREPLACE, COAL OR
WOOD STOVE? Yes  No

IS THERE A WINDOW IN THE HOUSE OR OFFICE SLIGHTLY OPEN (1/2 TO 1.0 INCH) OR DO YOU HAVE ANOTHER SOURCE OF FRESH AIR TO SUPPLY AIR TO THE STOVE SUCH AS DRAFTY CONDITIONS DUE TO OLD WINDOWS AND DOORS OR A FRESH AIR VENT    Yes  No

HAVE YOU USED A CHARCOAL GRILL OR HIBACHI POT FOR COOKING INDOORS, OR TO ELIMINATE THE
CHILL IN AN ENCLOSED SPACE OR ROOM? Yes  No

Never use charcoal grills or hibachi pots indoors for cooking or to eliminate the chill in a room or closed garage. The smoldering embers of charcoal produce great amounts of CARBON MONOXIDE. Always take care to grill away from the windows of your house.

IF YOU USE A VENT-LESS FIREPLACE, DO YOU LEAVE A WINDOW SLIGHTLY OPEN TOP AND BOTTOM
TO PROVIDE FRESH AIR IN THE ROOM?   Yes  No

SPACE HEATERS:   Yes  No   IF NO, GO ON TO NEXT SECTION (AUTOMOBILES AND SMALL ENGINES)

DO YOU USE THE PROPER FUEL IN KEROSENE POWERED SPACE HEATERS? Yes  No

IS THE SPACE HEATER VENTED TO THE OUTSIDE? Yes  No

DO YOU FOLLOW THE CAUTION INSTRUCTIONS THAT COME WITH THE SPACE HEATER DEVICE?    Yes  No

DO YOU SLEEP IN A ROOM WITH AN UNVENTED SPACE HEATER? Yes  No   This should be avoided if at all possible! Also, leave the window slightly open to allow for circulation of fresh air within the room where the space heater is located. Use a digital CO detector to monitor CO levels.

AUTOMOBILES AND SMALL ENGINES:

DO YOU EVER LET AN AUTOMOBILE IDLE (run in neutral) IN THE GARAGE? Yes  No  Do not idle automobiles in a garage.

DO YOU LEAVE THE GARAGE DOOR(S) OPEN FOR AT LEAST A FEW MINUTES AFTER YOU HAVE PULLED YOUR CAR INTO THE GARAGE.   Yes  No

DO YOU RUN OTHER INTERNAL COMBUSTION ENGINES (e.g. lawnmowers, chain saws, snow blowers, etc.) IN AN ENCLOSED SPACE LIKE A GARAGE OR BASEMENT?    Yes  No

DO YOU RUN OTHER INTERNAL COMBUSTION ENGINES (e.g. lawnmowers, chain saws, snow blowers, etc.) IN AN ENCLOSED SPACE LIKE A GARAGE OR BASEMENT?    Yes  No

CHEMICAL STORAGE:

ARE THERE ANY CHEMICALS INCLUDING GASOLINE, DIESEL FUEL, OILS, INDUSTRIAL CLEANING AGENTS,
OR OTHER SOLUTIONS STORED IN THE BUILDING?    Yes  No

ARE ANY BEAUTY PRODUCTS INLCUDING NAIL POLISH REMOVERS, PERFUMES, HAIR SPRAY PRESENT IN THE BUILDING IN QUANTITIES GREATER THAN A TYPICAL STORE BOUGHT PACKAGE?   Yes  No

DO YOU USE A PORTION OF YOUR BASEMENT OR ATTACHED GARAGE FOR A MACHINE SHOP, AUTO
REPAIR FACILITY OR OTHER INDUSTRIAL USE?    Yes  No

ODORS:

DO YOU NOTICE ODORS FROM YOUR DRINKING WATER?    Yes  No

DO ANY ODORS SMELL LIKE: ROTTEN EGGS, SEWER GASES, CHEMICALS,  PETROLEUM (gasoline, oils), PERFUMES, CLEAN CHEMICAL-LIKE, MUSTY/MOLDY

IF YOU NOTICE ANY OTHER ODORS IN THE BUILDING PLEASE DESCRIBE BELOW:
 

PLEASE COMMENT ON ANY OTHER CONDITIONS YOU ARE CONCERNED ABOUT IN YOUR HOME OR OFFICE.

 

 

 

 

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