OMB#
XXXX­
XXXX
Expiration
Date:
__/__/____

1
Date
_______________

Name
of
Person
Responding
_______________________________
Title
______________________

Name
of
School
____________________________________________________________________

Address
___________________________________________________________________________

City
___________________________________
State
_________
Zip
Code
____________________

County
__________________________
School
District
____________________________________

Phone
_________________
Fax
__________________
E­
mail
_______________________________

School
Type:
Public
___________
Grade
Levels:
Elementary_______________

Private
__________
Middle/
Jr.
High__________

Sr.
High________________

Other
__________________

No.
of
Students
__________________
No.
of
Faculty
and
Staff
_____________________________

School
Size
(
sq.
ft.)
____________
No.
of
Buildings
________
Age
of
School
(
yrs)_______________

HVAC
Type:
Central
Air
Handling
System
(
each
unit
serves
multiple
rooms)__________________

Unit
Ventilators
(
each
unit
serves
a
single
room)
_____________________________

Other
______________________________________________________________
U.
S.
Environmental
Protection
Agency's
(
EPA)
IAQ
Practices
in
Schools
Survey
1.
What
IAQ
Management
Program
are
you
using
in
your
school?
(
check
one)

(
a)
EPA's
Indoor
Air
Quality
Tools
for
Schools
(
b)
Other
_____________________________
(
c)
None
(
go
to
question
7)

2.
How
long
has
your
school
had
an
IAQ
management
plan?
(
check
one)


less
than
1
year

1­
2
years

2­
4
years

more
than
5
years
Questions
3­
7
ask
you
to
rate
certain
characteristics
of
your
school's
IAQ
program
on
a
scale
of
0
to
5
as
follows:

0
=
none,
not
at
all
3
=
moderate,
adequate
1
=
not
much,
poor
4
=
a
lot,
good
2
=
somewhat,
fair
5
=
very
much,
excellent
2
Rating
Scale
0
=
none,
not
at
all
2
=
somewhat,
fair
4
=
a
lot,
good
1
=
not
much,
poor
3
=
moderate,
adequate
5
=
very
much,
excellent
0
1
2
3
4
5
3.
Please
rate
the
quality
and
effectiveness
of
your
school's
IAQ
management
plan
(
rate
each
item)

A
person
is
designated
as
IAQ
coordinator/
manager
and
has
authority
to
carry
out
the
IAQ
management
plan
The
building
and
HVAC
system
receive
regular
maintenance
to
insure
that
all
systems
are
consistently
functioning
as
designed
IAQ
is
a
priority
consideration
for
repairs
and
upgrades
of
the
school
building
and
HVAC
system
The
HVAC
system
consistently
provides
adequate
control
of
temperature,
humidity
and
outdoor
air
ventilation
to
all
occupied
spaces
Art
classes,
industrial
art
classes,
and
science
laboratories
choose
products
and/
or
incorporate
specific
methods,
e.
g.,
exhaust
ventilation,
to
minimize
exposures
of
all
students
and
staff
to
pollutants
produced
from
these
activities
Housekeeping
(
custodial)
services
maintain
clean
conditions
in
all
areas
Administrative
and
custodial
staff
are
trained
to
read
and
follow
directions
for
all
cleaning
products
and
methods
to
minimize
exposure
of
staff
and
students
An
IAQ
walkthrough
inspection
along
with
periodic
check­
ups
are
used
to
monitor
IAQ
conditions
and
practices
in
the
school(
s)

4.
Pest
control
in
the
school(
s)
is
accomplished
using
the
following
(
rate
each
item)

Traps
are
used
to
monitor
pest
populations
Threshold
targets
are
established
for
pest
populations
Traps
are
used
to
kill
and
control
pests
Hygienic
conditions
are
strictly
maintained
to
prevent
infestations
Leaks,
spills,
condensation,
and
other
moisture
sources
are
strictly
controlled
Pesticides
are
applied
on
a
regular
basis
Rating
Scale
0
=
none,
not
at
all
2
=
somewhat,
fair
4
=
a
lot,
good
1
=
not
much,
poor
3
=
moderate,
adequate
5
=
very
much,
excellent
0
1
2
3
4
5
3
5.
School
personnel
actively
participate
in
the
IAQ
program
(
rate
participation
by
each
group)

Teachers
Administrative
staff
Custodial
staff
Food
service
staff
Health
Officers/
School
Nurses
Facilities
and
Maintenance
staff
Other
(
specify)

6.
Please
rate
the
extent
to
which
the
following
have
been
barriers
to
implementing
IAQ
practices
in
your
school(
s)

Potential
liability
Costs
Lack
of
resources
Lack
of
knowledge
Competing
priorities
School
administration
School
Board
7.
In
your
opinion,
has
your
IAQ
program
led
to
any
of
the
following?
(
check
all
that
apply)

Lower
Absenteeism
Better
Test
Scores
Increased
Productivity
Fewer
Asthma
Episodes
Improved
Work
Place
Satisfaction
Fewer
Visits
to
the
Health
Officer/
School
Nurse
8.
The
outdoor
air
ventilation
rate
in
your
school(
s)
is
set
at
(
check
one)

No
particular
setting
(
cfm
=
cubic
feet
per
minute)

less
than
5
cfm
per
occupant
4
5
to
10
cfm
per
occupant
11
to
14
cfm
per
occupant
15
or
more
cfm
per
occupant
STOP
HERE
IF
YOU
ARE
NOT
USING
IAQ
TOOLS
FOR
SCHOOLS!

9.
If
you
are
using
EPA's
IAQ
Tools
for
Schools,
the
following
IAQ
checklists
have
been
distributed
(
check
all
that
apply)

Teachers
Administrative
Staff
Health
Officers/
School
Nurses
Ventilation
Renovation
and
Repairs
Building
Maintenance
Food
Services
Waste
Management
Walkthrough
10.
If
you
are
using
EPA's
IAQ
Tools
for
Schools,
approximately
what
%
of
the
following
IAQ
checklists
have
been
completed
and
returned?
(
rate
each
item)
0­
25%
26­
50%
51­
75%
75­
100%

Teachers
Administrative
Staff
Health
Officers/
School
Nurses
Ventilation
Renovations
and
Repairs
Building
Maintenance
Food
Services
Waste
Management
Walkthrough
Burden
means
the
total
time,
effort,
or
financial
resources
expended
by
persons
to
generate
,
maintain,
retain,
or
disclose
or
provide
information
to
or
for
a
Federal
agency.
This
includes
the
time
needed
to
review
instructions;
develop,
acquire,
install,
and
utilize
technology
and
systems
for
the
purposes
of
collecting,
validating,
and
verifying
information,
processing
and
maintaining
information,
and
disclosing
and
providing
information;
adjust
the
existing
ways
to
comply
with
any
previously
applicable
instructions
and
requirements;
train
personnel
to
be
able
to
respond
to
a
collection
of
information;
search
data
sources;
complete
and
review
the
collection
of
information;
and
transmit
or
otherwise
disclose
the
information.
An
agency
may
not
conduct
or
sponsor,
and
a
person
is
not
required
to
respond
to,
a
collection
of
information
unless
it
displays
a
currently
valid
OMB
control
number.
5
