This form is to serve as primary notification of an Indoor Air Quality concern to the WKU IAQ Manager. Use this form to report to any concerns you have related to the indoor air quality in your workplace.  Indoor air quality concerns may include issues with temperature, humidity, ventilation, odors, or air pollutants that may be causing health or discomfort symptoms.  Your observations are a critical component of resolving IAQ concerns.  Please use the additional information section to specifically describe your concern. If you have questions when completing this form, contact Anita Britt at 745-2333.

*REQUIRED FIELDS 

*Name:

*Building/Room #:

*Date:

Department:

Title:

Floor Level:

Phone Number:

Employment Status: FT - PT       hrs/week

*What is the nature of the problem?

Where is the problem experienced (in one or more locations)?

*When was the problem first experienced?

*When does it occur or when is it the worst (time of day, day of week, related to certain activities/events)?

What do you think is the cause of the IAQ concern?

Additional Information:

File Number

_____________________     

Received By

 __________________________    

Date Received

  _________________________

ACTIONS TAKEN