This form can be filed out by the building occupant or by a member of the building staff.

Company/Tenant Name:___________________________________________________ Date:___________________
Department/Location in Building:____________________________________________ Phone:__________________
Completed by:______________________________________ Title:________________ Phone:__________________

This form should be used if your complaint may be related to indoor air quality. Indoor air quality problems include concerns with temperature control, ventilation, and air pollutants. Your observations can help to resolve the problem as quickly as possible. Please use the space below to describe the nature of the complaint and any potential causes.

We may need to contact you to discuss your complaint. What is the best time to reach you?__________________________

So that we can respond promptly, please return this form to:___________________________________________________ 
													IAQ Manager or Contact Person

									              		__________________________________________________ 
													Room, Building, Mail Code

OFFICE USE ONLY

File Number:__________________________Received By:_______________________ Date Received:_________________

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