Mold Symptom Survey Since Returning to School

The Louisiana Federation of Teachers is conducting this survey to determine the extent of health-related symptoms from mold at your facility. Please take a few minutes and complete it.

This survey is adapted from University of Connecticut Health Center, Guidance for Clinicians on the Recognition and Management of Health Effects Related to Mold Exposure and Moisture.

All responses are anonymous.

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* 1. 1. Do you currently have any illnesses, symptoms or discomfort that you attribute to conditions in your room or building?

Yes

Unsure

Question Title

* 2. If you answered yes, some symptoms maybe related to mold exposure. Are you troubled by:

	Yes/No	How is it at Home?	How is it at Work?
Waking up first thing in the morning with a feeling of tightness in your chest?	Waking up first thing in the morning with a feeling of tightness in your chest? Yes/No menu	Waking up first thing in the morning with a feeling of tightness in your chest? How is it at Home? menu	Waking up first thing in the morning with a feeling of tightness in your chest? How is it at Work? menu
Waking up during the night with shortness of breath?	Waking up during the night with shortness of breath? Yes/No menu	Waking up during the night with shortness of breath? How is it at Home? menu	Waking up during the night with shortness of breath? How is it at Work? menu
Waking up during the night by an attack of coughing?	Waking up during the night by an attack of coughing? Yes/No menu	Waking up during the night by an attack of coughing? How is it at Home? menu	Waking up during the night by an attack of coughing? How is it at Work? menu
Shortness of breath when you are not doing anything strenuous?	Shortness of breath when you are not doing anything strenuous? Yes/No menu	Shortness of breath when you are not doing anything strenuous? How is it at Home? menu	Shortness of breath when you are not doing anything strenuous? How is it at Work? menu
Worsening or more frequent asthma attacks?	Worsening or more frequent asthma attacks? Yes/No menu	Worsening or more frequent asthma attacks? How is it at Home? menu	Worsening or more frequent asthma attacks? How is it at Work? menu
Chills or fever?	Chills or fever? Yes/No menu	Chills or fever? How is it at Home? menu	Chills or fever? How is it at Work? menu
Aching all over?	Aching all over? Yes/No menu	Aching all over? How is it at Home? menu	Aching all over? How is it at Work? menu
Runny, blocked, or stuffy nose?	Runny, blocked, or stuffy nose? Yes/No menu	Runny, blocked, or stuffy nose? How is it at Home? menu	Runny, blocked, or stuffy nose? How is it at Work? menu
Headaches?	Headaches? Yes/No menu	Headaches? How is it at Home? menu	Headaches? How is it at Work? menu
Extreme or unusual lethargy and/or tiredness?	Extreme or unusual lethargy and/or tiredness? Yes/No menu	Extreme or unusual lethargy and/or tiredness? How is it at Home? menu	Extreme or unusual lethargy and/or tiredness? How is it at Work? menu
Frequent sinus congestion?	Frequent sinus congestion? Yes/No menu	Frequent sinus congestion? How is it at Home? menu	Frequent sinus congestion? How is it at Work? menu
Frequent nose bleeds?	Frequent nose bleeds? Yes/No menu	Frequent nose bleeds? How is it at Home? menu	Frequent nose bleeds? How is it at Work? menu
Hoarseness?	Hoarseness? Yes/No menu	Hoarseness? How is it at Home? menu	Hoarseness? How is it at Work? menu
Memory loss?	Memory loss? Yes/No menu	Memory loss? How is it at Home? menu	Memory loss? How is it at Work? menu
Nausea?	Nausea? Yes/No menu	Nausea? How is it at Home? menu	Nausea? How is it at Work? menu
Vomiting?	Vomiting? Yes/No menu	Vomiting? How is it at Home? menu	Vomiting? How is it at Work? menu
Diarrhea?	Diarrhea? Yes/No menu	Diarrhea? How is it at Home? menu	Diarrhea? How is it at Work? menu
Skin rashes?	Skin rashes? Yes/No menu	Skin rashes? How is it at Home? menu	Skin rashes? How is it at Work? menu

Comments

Question Title

* 3. If you have health symptoms while in this building, how long do they last after you have left the building?

Less than one hour

1-12 hours

Overnight

Longer than two days

None of the above

Other (please specify)

Question Title

* 4. Have you been diagnosed by a healthcare provider with any of the following since beginning work at your present facility?

	Yes	No
Asthma	Asthma Yes	Asthma No
Chronic bronchitis	Chronic bronchitis Yes	Chronic bronchitis No
Chronic sinusitis or sinus infection	Chronic sinusitis or sinus infection Yes	Chronic sinusitis or sinus infection No
Sarcoidosis	Sarcoidosis Yes	Sarcoidosis No
Allergies	Allergies Yes	Allergies No
Other illness you associate with your workplace	Other illness you associate with your workplace Yes	Other illness you associate with your workplace No

Question Title

* 5. Does your room have any visible mold growth?

Yes

Question Title

* 6. If so, where in the room is the mold growing?

Question Title

* 7. Is there evidence of water leaks in your room? (i.e., water stains on tile, walls, or carpet)

Yes

Question Title

* 8. If so, where in the room are the water leaks?

Question Title

* 9. Please describe any other conditions/problems that may be contributing to your discomfort and/or symptoms.

Question Title

* 10. Job classification

Teacher

Other Professional

Classroom Paraprofessional

Secretary

Custodial/Maintenance

Transportation

Other (please specify)

Question Title

* 11. How many years have you worked at your current location?

Less than one year

1-5 years

6-10 years

11-15 years

16-20 years

More than 20 years

Question Title

* 12. Optional: Name and Email

Name

Email Address

Phone Number

Question Title

* 13. Parish

Jefferson Parish

St. Tammany Parish

Tangipahoa Parish

Livingston Parish