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The Professional Screening Partner Program

Solution-Based Assessment for Indoor Environments

You have been provided with this survey by a NORMI trained and Certified Professional Screening Partner. If you choose to have your home assessed for possible indoor air quality problems, your PSP technician will provide you with an as-sessment sample kit. The assessment sam-ple kit has been designed using the same methods and procedures that environmental consultants use when inspecting indoor air environments for possible indoor air quality problems. You may choose to conduct the as-sessment yourself following the PSP pro-gram, or you may elect to have your PSP partner assist you in the assessment pro-cess. Your PSP partner may charge you a nominal service fee for providing such over-sight services. The basic cost of each lab assessment kit, including a lab report, is $99. Assessing your environment to de-fine IAQ problems must be accomplished before proper solutions can be designed to improve your indoor air quality. Take the best first step to improving your indoor air quality. Call or email your Professional Screening Partner today.

PLEASE PRINT CLEARLY

Name:

Address:

City:

ST: ZIP:

Phone:

eMail:

Are you concerned about the air

quality within your home? Maybe there is a

problem, and maybe there isn’t. How do

you know?

The first step in defining indoor air

quality problems is gathering information.

When environmental consultants inspect

homes the standard method they use is sur-

vey, assess, sample and solve. By filling out

the information on the IAQ survey you will

have completed the first step in gathering

the information necessary to define the in-

door air quality of your home.

Common Contaminants

● Dust (mixed) ● Pollen

● Dead Skin ● Mold Spores

● Pet Dander ● Chemical VOCs

● Dustmites ● Bacteria

● Insect Parts ● Dirt

8) Do you want to improve the indoor air

quality within your home?

Yes No

If you rated your home between a

one to seven, or are experiencing health

problems you probably want to continue

gathering data. We can assist you in as-

sessing your home by providing you with

an assessment kit that includes two sam-

ples (additional samples could be includ-

ed). Areas assessed will include heat-

ing/cooling systems, general living areas,

and moisture prone areas. Surface sam-

ples will be sent to a laboratory for analysis

quantifying common indoor contaminants

within your home.

9) Do you want your home assessed, and

samples taken for laboratory analysis? The

total cost for the assessment and sample

package is $99.00.

Yes No

1) On a scale of 1-10, with 1 being poor

and 10 being excellent, how would you

rate the Indoor Air Quality in your home?

Poor Excellent

2) Are there areas within your home that

have odors, dampness, water issues,

mold?

Yes No

3) Do you believe any of the following

area within your home have IAQ prob-

lems: (check as many as apply) Bedroom Living Room Attic Space

Kitchen Bathroom HVAC System

Basement Crawlspace Family Room

4) Do you have any animals?

Yes No

5) Do you have carpeting in: (check) Bedroom Living Room Dining Room

Hallways Bathroom Playroom

Basement Den Other rooms

6) Are any family members living at

home experiencing itchy skin, watery

eyes, runny noses, sneezing, coughing,

allergies, asthma, or lung problems?

Yes No

7) Do you believe Indoor Air Quality

Problems might be contributing to sick-

ness or allergic reactions in your home?

Yes No

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