6630204 - Mold Response Form

6630204 - Mold Response Form

APPENDIX A: MOLD FIRST RESPONSE FORM
Date:*

MonthDayYear
Date
Indoor Temperature:*
Time:*

Hour Minutes

AM/PM Option
Indoor Relative Humidity:*
Location of Mold (Building Number, Room Number etc.):*
YesNo
0-30 SF30-100 SF>100 SF
Mold is on blank* surface. (e.g. drywall, wood)
List any visible water/moisture source:*
YesNo
Please describe:
YesNo
Additional Comments:
Found by:
Name:*
Company:*
PCL Employee:*
Forward to District Safety Manager - Action Required 24 - 48 Hours
Should be Empty: