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IAQ Incident Report Form

This is to document in real time the problem you are experiencing. The information will be forwarded to a specialist in the Occupational Health and Hygiene Division of Environmental Health and Safety.

Employee/Student Name: (For EHS follow up, a name is required.)

Are there others affected? If so, they must also complete this Incident report form.

Telephone:

Location of the Incident:(Room/Bldg)

Date of Occurrence:

Time and Duration: (e.g. began at 2:45pm and lasted 20 minutes; lasted all day.)

Please describe the occurrence:

Any Medical Symptoms?

Do you know of anything that may have contributed to this incident? (i.e. water dripping down the wall)

Any unusual activities in the area? (construction, building maintenance, etc.)

Weather Conditions? (Windy, dusty, raining, snowing)

Have you reported this before? If so, to whom?

Other Comments?