Title Page

  • Date of Request

  • Date of Inspection

  • Address
  • Housing Type

  • Project Number

  • Type of Inspection

  • Inspector

Living Room

  • Living Room Present <br>Is there a living room?

  • Electricity <br>Are there at least two working outlets or one working outlet and one working light fixture?

  • Electrical Hazards <br>Is the room free from electrical hazards?

  • Security <br>Are all windows and doors that are accessible from the outside lockable?

  • Window Condition <br>Is there at least one window, and are all windows free of signs of severe deterioration or missing or broken out panes?

  • Ceiling Condition <br>Is the ceiling sound and free from hazardous defects?

  • Wall Condition <br>Are the walls sound and free from hazardous defects?

  • Floor Condition <br>Is the floor sound and free from hazardous defects?

  • Lead-Based Paint <br>Are all painted surfaces free of deteriorated paint?

  • Do deteriorated surfaces exceed two square feet and/or more than 10% of a component?

Kitchen

  • Kitchen Area Present <br>Is there a kitchen?

  • Electricity<br>Are there at least one working outlet and one working, permanently installed light fixture?

  • Electrical Hazards <br>Is the kitchen free from electrical hazards?

  • Security <br>Are all windows and doors that are accessible from the outside lockable?

  • Window Condition <br>Are all windows free of signs of deterioration or missing or broken out panes?

  • Ceiling Condition <br>Is the ceiling sound and free from hazardous defects?

  • Wall Condition <br>Are the walls sound and free from hazardous defects?

  • Floor Condition <br>Is the floor sound and free from hazardous defects?

  • Lead-Based Paint <br>Are all painted surfaces free of deteriorated paint?

  • Do deteriorated surfaces exceed two square feet and/or more than 10% of a component?

  • Stove or Range with Oven <br>Is there a working oven, and a stove (or range) with top burners that work?

  • If no oven and stove (or range) are present, is there a microwave oven and, if the microwave is owner-supplied, do other tenants have microwaves instead of an oven and stove (or range)?

  • Refrigerator <br>Is there a refrigerator that works and maintains a temperature low enough so that food does not spoil over a reasonable period of time?

  • Sink <br>Is there a kitchen sink that works with hot and cold running water?

  • Space for Storage, Preparation, and Serving Serving of Food <br>Is there space to store, prepare, and serve food?

Bathroom

  • Bathroom Present (See description) <br>Is there a bathroom?

  • Electricity <br>Is there at least one permanently installed light fixture?

  • Electrical Hazards <br>Is the bathroom free from electrical hazards?

  • Security <br>Are all windows and doors that are accessible from the outside lockable?

  • Window Condition <br>Are all windows free of signs of deterioration or missing or broken out panes?

  • Ceiling Condition <br>Is the ceiling sound and free from hazardous defects?

  • Wall Condition <br>Are the walls sound and free from hazardous defects?

  • Floor Condition <br>Is the floor sound and free from hazardous defects?

  • Lead-Based Paint <br>Are all painted surfaces free of deteriorated paint?

  • Do deteriorated surfaces exceed two square feet and/or more than 10% of a component?

  • Fixed Wash Basin or Lavatory in Unit <br>Is there a working, permanently installed washbasin with hot and cold running water in the unit?

  • Tub or Shower <br>Is there a working tub or shower with hot and cold running water in the unit?

  • Ventilation <br>Are there operable windows or a working vent system?

  • Other Rooms Used for Living and Halls

Room Location

  • Location

Room Code

  • 1 = Bedroom or Any Other Room Used for Sleeping (regardless of the type of room)
    2 = Dining Room or Dining Area
    3 = Second Living Room, Family Room, Den, Playroom, TV Room
    4 = Entrance Halls, Corridors, Halls, Staircases
    5 = Additional Bathroom (also check the presence of sink trap and clogged toilet)
    6 = Other

  • Room Code

  • Electricity/Illumination <br>If Room Code is a 1, are there at least two working outlets or one working outlet and one working, permanently installed light fixture?

  • If Room Code is not a 1, is there a means of illumination?

  • Electrical Hazards <br>Is the room free from electrical hazards?

  • Security <br>Are all windows and doors that are accessible from the outside lockable?

  • Window Condition <br> If Room Code is a 1, is there at least one window?

  • Regardless of Room Code, are all windows free of signs of severe deterioration or missing or broken-out panes?

  • Ceiling Condition <br>Is the ceiling sound and free from hazardous defects

  • Wall Condition <br>Are the walls sound and free from hazardous defects?

  • Floor Condition <br>Is the floor sound and free from hazardous defects?

  • Lead-Based Paint <br>Are all painted surfaces free of deteriorated paint?

  • Do deteriorated surfaces exceed two square feet and/or more than 10% of a component?

  • Smoke Detectors <br>Is there a working smoke detector on each level?

  • Do the smoke detectors meet the requirements of NFPA 74?

  • In units occupied by the hearing impaired, is there an alarm system connected to the smoke detector?

All Secondary Rooms (Rooms not used for living)

  • Security <br>Are all windows and doors that are accessible from the outside lockable?

  • Electrical Hazards <br>Are all these rooms free from electrical hazards?

  • Other Potentially Hazardous Features <br>Are all of these rooms free of any other potentially hazardous features? <br>For each room with an "other potentially hazardous feature," explain the hazard and the means of control of interior access to the room.

Building Exterior

  • Condition of Foundation <br>Is the foundation sound and free from hazards?

  • Condition of Stairs, Rails, and Porches <br>Are all the exterior stairs, rails, and porches sound and free from hazards?

  • Condition of Roof and Gutters <br>Are the roof, gutters, and downspouts sound and free from hazards?

  • Condition of Exterior Surfaces <br>Are exterior surfaces sound and free from hazards?

  • Condition of Chimney <br>Is the chimney sound and free from hazards?

  • Lead-Based Paint: Exterior Surfaces <br>Are all painted surfaces free of deteriorated paint?

  • If no, does deteriorate surfaces exceed 20 sq. ft. of total exterior surface area?

  • Manufactured Homes: Tie Downs <br>If the unit is a manufactured home, is it properly placed and tied down? <br>If not a manufactured home, type in notes as "Not Applicable."

Heating and Plumbing

  • Adequacy of Heating Equipment <br>Is the heating equipment capable of providing adequate heat (either directly or indirectly) to all rooms used for a living?

  • Safety of Heating Equipment <br>Is the unit free from unvented fuel-burning space heaters or any other types of unsafe heating conditions?

  • Ventilation and Adequacy of Cooling <br>Does the unit have adequate ventilation and cooling by means of openable windows or a working cooling system?

  • Water Heater<br>Is the water heater located, equipped, and installed in a safe manner?

  • Water Supply <br>Is the unit served by an approvable public or private sanitary water supply?

  • Plumbing <br>Is plumbing free from major leaks or corrosion that causes serious and persistent levels of rust or contamination of the drinking water?

  • Sewer Connection <br> Is plumbing connected to an approvable public or private disposal system, and is it free from sewer back-up?

General Health and Safety

  • Access to Unit <br>Can the unit be entered without having to go through another unit?

  • Exits <br>Is there an acceptable fire exit from this building that is not blocked?

  • Evidence of Infestation <br>Is the unit free from rats or severe infestation by mice or vermin?

  • Garbage and Debris <br>Is the unit free from heavy accumulation of garbage or debris inside and outside?

  • Refuse Disposal <br>Are there adequate covered facilities for temporary storage and disposal of food wastes, and are they approvable by a local agency?

  • Interior Stairs and Common Halls <br>Are interior stairs and common halls free from hazards to the occupant because of loose, broken, or missing steps on stairways; absent or insecure railings; inadequate lighting; or other hazards?

  • Other Interior Hazards <br>Is the interior of the unit free from any other hazard not specifically identified previously?

  • Elevators <br>Where local practice requires, do all elevators have a current inspection certificate? If local practice does not require this, are they working and safe?

  • Interior Air Quality <br>Is the unit free from abnormally high levels of air pollution from vehicular exhaust, sewer gas, fuel gas, dust, or other pollutants?

  • Site and Neighborhood Conditions <br>Are the site and immediate neighborhood free from conditions which would seriously and continuously endanger the health or safety of the residents?

  • Lead-Based Paint: <br>Has certification been completed, and received by the PHA?

Sign Off

  • Additional Recommendations

  • Inspector Name and Signature

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