No	Facility & Room Name:	Grades Rubric	Survey Points
1	Is the ventilation system on?	Yes = 70 pts
2	If the ventilation system is not On do you have access to turn On the ventilation system?	Yes = 50 pts
3	If the ventilation system was not On, did you turn on the ventilation system upon room entry?	Yes = 20 pts
4	Can you feel the ventilation on your face?	Yes = 10 pts
5	Do the vents have 6 or more feet of clearance?	No = -10 pts
6	Is the ACH level posted in the room?	Yes = 10 pts
7	If the ACH level is posted is it greater than 5 ACH?	Yes = 5 pts
8	If the ACH level is posted is it greater than 6 ACH?	Yes = 6 pts
9	If the ACH level is posted is it greater than 12 ACH?	Yes = 20 pts
10	Have you been told that there is a Ceiling Level UV system and that it is On?	Yes = 100 pts
11	Have you been told that there is a FAR UV system installed and that it is On?	Yes = 100 pts
12	Can you smell perfumes?	Yes = -100 pts
13	Can you smell food?	Yes = -50
14	Can you smell mildew or mold?	Yes = -50
15	Is the space stuffy?	Yes = -25
16	Are the vents dirty?	Yes = -10
17	Did you search the Facility Ventilation Search Engine - FVSE for this space?	Yes = 5
18	If you did not find this space in the FVSE database, did you add this space to the database?	Yes = 5
19	Manually add the values and print or save this completed form.	Total
20	Determine the Rating. Poor < 70, Average 70-80, Better 81-90, Good 91-94, Excellent 95+ Any score below 95 will benefit from a Quality Improvement program at: QIDC.	Rating

No	Room Name:	Grades Rubric	Survey Points
1	When there are visitors do you turn On the fan option on your thermostat?	Yes = 70 pts
2	Do you leave your fan on for 1 hour after visitors leave?	No = -10 pts
3	If there is no fan option do you open the windows or doors to allow for natural ventilation?	Yes = 70 pts
4	If there is no fan option do you leave the windows or doors open for 1 hour after visitors leave?	No = -10 pts
5	If someone has a respiratory illness do they isolate themselves?	No = -20 pts
6	If someone has a respiratory illness do you turn On the fan option on your thermostat?	No = -20 pts
7	If someone has a respiratory illness and there is no fan option, are windows open in the isolation area?	No = -20 pts
8	Are the vents fully Open in all rooms?	Yes = 5 pts
9	Is there less than 6 feet of clearance for each vent?	Yes = -10 pts
10	Have you found the model number of your HVAC system and determined the fan CFM size?	Yes = 5 pts
11	Have you determined your residence ACH design level? ACH = fan CFM * 60 / residence square feet * average room height	Yes = 5 pts
12	Have you measured the ACH level in each room when the fan in On?	Yes = 5 pts
13	If the room has a Ceiling Level UV system, is the system on?	Yes = 70 pts
14	If the room has a Far UV system, is the system on?	Yes = 70 pts
15	If the room has a room sanitizer system, is the system on?	Yes = 5 pts
16	Manually add the values and print or save this completed form.	Total
17	Determine the Rating. Poor < 70, Average 70-80, Better 81-90, Good 91-94, Excellent 95+ Any score below 95 will benefit from a Quality Improvement program at: QIDC.	Rating

No	Room Name:	Grades Rubric	Survey Points
1	Is ventilation system On in all rooms and does not turn Off because of temperature, humidity, or any other external influences including automatic controls and external energy management companies?	Yes = 70 pts
2	Are the vents fully Open in all rooms?	Yes = 5 pts
3	If applicable, are wire mesh filters dirty?	Yes = -10 pts
4	If applicable, are vent filters dirty?	Yes = -10 pts
5	Is there less than 6 feet of clearance for each vent?	Yes = -10 pts
6	Vents do not blow on Occupants?	Yes = 5 pts No = -10 pts
7	Are there stains on the ceiling?	Yes = -10 pts
8	Are there stains in the room suggesting previous moisture events?	Yes = -10 pts
9	Are there stains in the room suggesting mold?	Yes = -10 pts
10	If the room has an Exhaust Fan, does it turn on and off?	No = -10 pts
11	If the room has a handheld or fixed anemometer all the vents show greater than 100 FPM?	Yes = 5 pts
12	If the room has a handheld or fixed anemometer all the vents show greater than 200 FPM?	Yes = 5 pts
13	If the room has a handheld or fixed anemometer all the vents show greater than 300 FPM?	Yes = 5 pts
14	If the room has a Ceiling Level UV system, is the system on?	Yes = 70 pts
15	If the room has a Far UV system, is the system on?	Yes = 70 pts
16	If the room has a room sanitizer system, is the system on?	Yes = 5 pts
17	Manually add the values and print or save this completed form.	Total
18	Determine the Rating. Poor < 70, Average 70-80, Better 81-90, Good 91-94, Excellent 95+ Any score below 95 will benefit from a Quality Improvement program at: QIDC.	Rating

No	Room Name:	Grades Rubric	Survey Points
1	Is the room Total ACH Level 0?	Yes = 0 pts
2	Is the room Total ACH Level 1?	Yes = 0 pts
3	Is the room Total ACH Level 2	Yes = 5 pts
4	Is the room Total ACH Level 3?	Yes = 10 pts
5	Is the room Total ACH Level 4?	Yes = 15 pts
6	Is the room Total ACH Level 5?	Yes = 50 pts
7	Is the room Total ACH Level 6?	Yes = 71 pts
8	Is the room Total ACH Level 7?	Yes = 75 pts
9	Is the room Total ACH Level 8?	Yes = 81 pts
10	Is the room Total ACH Level 9?	Yes = 85 pts
11	Is the room Total ACH Level 10?	Yes = 91 pts
12	Is the room Total ACH Level 11?	Yes = 95 pts
13	Is the room Total ACH Level 12+?	Yes = 100 pts
14	Manually add the values and print or save this completed form. If there are no surveys enter 0 for the total.	Total
15	Determine the Rating. Unacceptable 0 - 4, Poor < 70, Average 70-80, Better 81-90, Good 91-94, Excellent 95+ Any score below 95 will benefit from a Quality Improvement program at: QIDC.	Rating

No	Operations Facility Name:	Grades Rubric	Survey Points
1	Are DCV HVAC controls set so that the ventilation remains constant throughout the day?	No = -40 pts
2	Are DCV HVAC controls set to maximize ACH levels?	Yes = 5 pts
3	Are DCV HVAC controls set to maximize fresh air intake?	Yes = 5 pts
4	Are On Demand HVAC fans set from Auto to On so that the ventilation is On?	Yes = 10 pts
5	Are there signs at each thermostat to turn On the system fans with simple instructions?	Yes = 20 pts
6	Is ventilation system On and constantly blowing air when more than 1 person is present no later than 1-2 hours before occupants arrive?	Yes = 50 pts
7	Does the ventilation stay On regardless of temperature, humidity, or occupant level?	Yes = 10 pts
8	Is the ventilation system Off no sooner than 1-2 hours after occupants leave?	Yes = 10 pts
9	Manually add the values and print or save this completed form. If there are no surveys enter 0 for the total.	Total
10	Determine the Rating. Unacceptable 0 - 4, Poor < 70, Average 70-80, Better 81-90, Good 91-94, Excellent 95+ Any score below 95 will benefit from a Quality Improvement program at: QIDC.	Rating

Note: Demand Controlled Ventilation (DCV) not to be confused with On Demand systems.

No	Maintenance Facility Name:	Grades Rubric	Survey Points
1	Are maintenance records on file in the office?	No = -10 pts
2	Are thermostat batteries replaced so that Fan status is always visible?	Yes = 50 pts
3	Are there certificates at each thermostat showing the last maintenance date?	No = -10 pts
4	Are all HVAC fans in all zones operating?	Yes = 50 pts
5	If there are Exhaust fans, are all Exhaust fans operating?	No = -10 pts
6	If there are vent streamers on the vents do they show that the system is running?	No = -10 pts
7	If there are ventilation complaints, have the vents have been adjusted or the vent types changed so that there are no complaints and the vents are open?	No = -10 pts
8	Does the facility use MERV 13 or higher filters?	No = -10 pts
9	Are HVAC filters clean and do not restrict airflow.	No = -10 pts
10	Are HVAC filters replaced a minimum of every 6 months?	No = -10 pts
11	Manually add the values and print or save this completed form. If there are no surveys enter 0 for the total.	Total
12	Determine the Rating. Unacceptable 0 - 4, Poor < 70, Average 70-80, Better 81-90, Good 91-94, Excellent 95+ Any score below 95 will benefit from a Quality Improvement program at: QIDC.	Rating

No	Ventilation Measurement Facility Name:	Grades Rubric	Survey Points
1	Have ACH levels been measured in all rooms?	Yes = 100
2	Have ACH levels been measured in half rooms?	Yes = 50
3	Have ACH levels been measured in some rooms?	Yes = 40
4	If there are eACH systems, have the eACH levels been provided?	No = -20
5	If ACH levels have been determined are the ACH levels on file in the office?	No = -10
6	If ACH levels are determined, have they been posted in each room?	No = -5
7	If eACH levels have been determined are the eACH levels on file in the office?	No = -10
8	If eACH levels are determined, have they been posted in each room?	No = -5
9	If ACH levels have been determined there are no areas that have zero or low ACH ventilation readings?	No = -20
10	Are there ACH levels that are less than 5 ACH?	Yes = -10
11	Are there ACH levels that are less than 10 ACH?	Yes = -5
11	Are there ACH levels greater than 12 ACH?	Yes = 10
12	For new construction have ACH and eACH levels been disclosed on the Internet?	Yes = 20
13	Manually add the values and print or save this completed form. If there are no surveys enter 0 for the total.	Total
14	Determine the Rating. Unacceptable 0 - 4, Poor < 70, Average 70-80, Better 81-90, Good 91-94, Excellent 95+ Any score below 95 will benefit from a Quality Improvement program at: QIDC.	Rating