AIR-CONDITIONING QUESTIONNAIRE

This questionnaire is designed for you to comment on the effects of the air-conditioning system at your workplace. There is no need to put your name on the questionnaire and all answers will remain confidential. Please forward the completed questionnaire to (name) ___________________________________:

Have you at any time over the past 12 months experienced discomfort or illness you believe is a result of poor ventilation or temperature control in your workplace? YES NO

If you experienced air-conditioning discomfort in the past 12 months then please indicate the type of discomfort. (Circle a number to indicate the severity.) Discomfort Severity (Low High) Too Hot 1 2 3 4 5 Too Cold 1 2 3 4 5 Stuffy 1 2 3 4 5 Draughty 1 2 3 4 5 Humid 1 2 3 4 5 Dry 1 2 3 4 5 If you experienced illness related to air-conditioning at work, then please indicate the type of illness. (Tick in the relevant brackets.) Sore Throat ( ) Nasal congestion ( ) Runny Nose ( ) Fits of coughing ( ) Pains on breathing, shortness of breath ( ) Fever, Chills Muscular ache Malaise ( ( ) ) Headaches ( ) ( ) Nausea and Vomiting ( ) ( ) Fits of sneezing

Have you had any of the following respiratory illnesses over the past 12 months? How often? Colds ( ) _______________ Bronchitis ( ) _______________ Pneumonia ( ) _______________ Flu ( ) _______________ Have you suffered any of the following allergy-based illnesses over the past 12 months? How often? Allergic rhinitis ( ) _______________ Sinusitis ( ) _______________ Asthma ( ) _______________ Hay Fever ( ) _______________ Humidifier Fever ( ) _______________ Hypersensitivity pneumonitis( ) _______________ How many days off work do you estimate you have taken over the past 12 months as a result of air-conditioningrelated illness? __________________ For any of these days, have you applied for: Sick Leave ( ) Workers' Compensation ( )

? ?