House Holder Completion Survey

• Audit Title

• Document No.

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

• House and or house holder.

  Media

• Select date

  Date

House Holder

• House holder explained the decontamination process.<br>

  Yes

  No

  N/A

• House holder happy with Decontamination Medix staff.

  Yes

  No

  N/A

• Decontamination medix left the house clean and tidy removing all rubbish and equipment as required.

  Yes

  No

  N/A

• The house was reinstated to its original or better state with no damage occurring.

  Yes

  No

  N/A

• Decontamination process of the house was carried out in a timely and professional manner.

  Yes

  No

  N/A

• Decontamination was fully completed as explained by the technician and the house holder is happy to sign off as completed.

  Yes

  No

  N/A

• Further notes or comments.

• House holder certifies that the above is true and correct.

  Sign

• Technicians signature

  Sign