Responding to Indoor Mold Concerns: A Resource for Environmental Public Health Professionals
Appendix B: Indoor Mold Assessment Form Resident & Home Information
Resident Name: Home Address:
Contact Information: Assessment Date:
Interview Questions
QUESTION
RESPONSE COMMENTS
YES □ NO □ YES □ NO □ YES □ NO □ YES □ NO □ YES □ NO □ YES □ NO □ YES □ NO □ YES □ NO □ YES □ NO □
Is mold visible on ceilings, walls, floors, or other areas?
Are occupants reporting symptoms possibly related to mold exposure (e.g., coughing, sneezing, headaches)?
Is there visible water damage or staining?
Is a musty or earthy odor present?
Was the home previously affected by flooding?
Is a humidifier or air conditioner available?
Are there any known roof leaks?
Are there any known plumbing leaks?
Does condensation accumulate on windows?
NOTES
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