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Indoor Air Quality Complaint Form

Problems related to indoor environmental conditions at all Christina School District facilities will be addressed by the district's Facilities Services Department. Please fill out this form to share your concerns.

*To maintain HIPPA compliance, any medical condition or protected information must be documented and coordinated through the INSERT HUMAN RESOURCE OFFICE, PERSONNEL DEPARTMENT, or NURSE’S OFFICE/OTHER HERE.
Date

MonthDayYear
Date
Name*

First NameLast Name
Address 1*
Address 2
City*
State*
Zip*
Preferred Phone Number*
Please provide the best contact number for you in the (xxx) xxx-xxxx format.
Email*

Location of Concern
Building*
Room Name / Number*
Location within Room*
Description of Concern

This form should be used if your complaint may be related to indoor air quality within a Christina School District facility. 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 this space to describe the nature of the complaint and any potential causes.*
Should be Empty:

Location of Concern