Minnesota Department of Health (MDH) Asthma Program
Environmental Triggers of Asthma – Room by Room School Walkthrough Checklist
Date of Walkthrough:_______________
Area or
Room
Number
Odors
Temperature
(hot/cold)
Animals
(number/
type)
School Name:_______________________________________
Page _____ of _____
Moisture
and/or
Mold
Ceiling
Stains
(Y/N)
Carpet
(Y/N)
Sink
(near
carpet)
Bathroom
Facilities
Pest/Vermin
Evidence
Cleaning
Products/
Chemicals/
Fragrance
Products
Plants
(number/
water tray)
Upholstered
Furniture or
Stuffed
Animals
Appliances, e.g.,
mini-refrigerator
air cleaner
microwave
humidifier
Walk-off
Mats for
Outside
Doors
Overall
Cleanliness
(such as
clutter/dust)
Moisture
and/or
Mold
Ceiling
Stains
(Y/N)
Carpet
(Y/N)
Sink
(near
carpet)
Bathroom
Facilities
Pest/Vermin
Evidence
Cleaning
Products/
Chemicals/
Fragrance
Products
Plants
(number/
water tray)
Upholstered
Furniture or
Stuffed
Animals
Appliances, e.g.,
mini-refrigerator
air cleaner
microwave
humidifier
Walk-off
Mats for
Outside
Doors
Overall
Cleanliness
(such as
clutter/dust)
Moisture
and/or
Mold
Ceiling
Stains
(Y/N)
Carpet
(Y/N)
Sink
(near
carpet)
Bathroom
Facilities
Pest/Vermin
Evidence
Cleaning
Products/
Chemicals/
Fragrance
Products
Plants
(number/
water tray)
Upholstered
Furniture or
Stuffed
Animals
Appliances, e.g.,
mini-refrigerator
air cleaner
microwave
humidifier
Walk-off
Mats for
Outside
Doors
Overall
Cleanliness
(such as
clutter/dust)
Moisture
and/or
Mold
Ceiling
Stains
(Y/N)
Carpet
(Y/N)
Sink
(near
carpet)
Bathroom
Facilities
Pest/Vermin
Evidence
Cleaning
Products/
Chemicals/
Fragrance
Products
Plants
(number/
water tray)
Upholstered
Furniture or
Stuffed
Animals
Appliances, e.g.,
mini-refrigerator
air cleaner
microwave
humidifier
Walk-off
Mats for
Outside
Doors
Overall
Cleanliness
(such as
clutter/dust)
Moisture
and/or
Mold
Ceiling
Stains
(Y/N)
Carpet
(Y/N)
Sink
(near
carpet)
Bathroom
Facilities
Pest/Vermin
Evidence
Cleaning
Products/
Chemicals/
Fragrance
Products
Plants
(number/
water tray)
Upholstered
Furniture or
Stuffed
Animals
Appliances, e.g.,
mini-refrigerator
air cleaner
microwave
humidifier
Walk-off
Mats for
Outside
Doors
Overall
Cleanliness
(such as
clutter/dust)
Comments including room use:
Area or
Room
Number
Odors
Temperature
(hot/cold)
Animals
(number/
type)
Comments including room use:
Area or
Room
Number
Odors
Temperature
(hot/cold)
Animals
(number/
type)
Comments including room use:
Area or
Room
Number
Odors
Temperature
(hot/cold)
Animals
(number/
type)
Comments including room use:
Area or
Room
Number
Odors
Temperature
(hot/cold)
Animals
(number/
type)
Comments including room use:
Marks: NP = No Problem; NA =Not Applicable
March 2009
How to Complete the MDH Asthma Program Room by Room School Walkthrough Checklist*
Odors: Does the room have a noticeable odor including food, mold and fragrances (Y/N)? Record the type of odor.
Temperature: Is the room too hot or cold?
Animals: Does the classroom have animals? If yes, record the type of animal and how many. Is the cage or habitat well maintained? If fish are kept in the
room, is the tank near or on carpeting or another porous material?
Moisture/Mold: Does the room have visible mold or a noticeable mold odor (Y/N)? Record the location of the mold.
Ceiling Stains: Does the ceiling have water stains (Y/N)? If yes, record the approximate number and size.
Carpet: Is the room carpeted (Y/N)?
Sink: Does the room have a sink (Y/N)? If yes, is the sink located near carpeting or other porous materials?
Bathroom: Does the room have bathroom facilities (Y/N)? If yes, is the bathroom clean? Is there a noticeable odor?
Pests: Is there evidence of mice, cockroaches, ants, flies or other pests (Y/N)? What type of pest? Do you see traps or baits?
Cleaning Products/Chemicals/Fragrance Products: Do you see cleaning products/chemicals/scented products (Y/N)? Is yes, are they district purchased
or approved. Scented products include air fresheners, diffusion sticks, and scented candles.
Plants: Are live plants in the room (Y/N)? If yes, how many and does each container have a solid bottom or tray to catch water.
Upholstered Furniture/Stuffed Animals: Do you see upholstered furniture, pillows, throw rugs or stuffed animals (Y/N)? If yes, record the type and
number.
Appliances: Does the room have appliances such as mini-refrigerators, portable air cleaners, microwaves, or humidifiers (Y/N)? If yes, record the type
and number. Also record if the appliance is located on or near carpeting.
Walk-off Mats: If the room has an outside door, is there a walk-off mat?
Cleanliness: Is there excessive clutter or dust in the room (Y/N)? If yes, record whether it is clutter, dust or both and the location.
*The emphasis is on issues with a low to no cost solution. For more information on the MDH Asthma Program school walkthrough project including a
summary fact sheet, a sample reporting form and the walkthrough forms, go to http://www.health.state.mn.us/asthma/schools.html.
March 2009