Indoor Air Quality ESA Screening Form
General Information
Date
Site Name
Location
Assessor Name
Contact
Building Information
Building Type
Approximate Age
Number of Occupants
HVAC System Present?
Yes
No
Observations
Any noticeable odors?
Yes
No
If yes, describe
Visible mold or moisture?
Yes
No
If yes, describe
Other concerns or observations
Complaints
Any occupant complaints?
Yes
No
If yes, describe
Summary/Recommendations