HQS Inspection Form

Title Page

Date of Request
Date of Inspection
Address
Housing Type
- Single Family Detached
- Duplex or Two Family Row
- House or Town House
- Low Rise: 3,4 Stories, Including Garden Apartment
- High Rise; 5 or More Stories
- Manufactured Home
- Congregate
- Cooperative
- Independent Group Residence
- Single Room Occupancy
- Shared Housing
Project Number
Type of Inspection
Inspector

Living Room

Living Room Present Is there a living room?
Electricity Are there at least two working outlets or one working outlet and one working light fixture?
Electrical Hazards Is the room free from electrical hazards?
Security Are all windows and doors that are accessible from the outside lockable?
Window Condition Is there at least one window, and are all windows free of signs of severe deterioration or missing or broken out panes?
Ceiling Condition Is the ceiling sound and free from hazardous defects?
Wall Condition Are the walls sound and free from hazardous defects?
Floor Condition Is the floor sound and free from hazardous defects?
Lead-Based Paint 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 Is there a kitchen?
Electricity Are there at least one working outlet and one working, permanently installed light fixture?
Electrical Hazards Is the kitchen free from electrical hazards?
Security Are all windows and doors that are accessible from the outside lockable?
Window Condition Are all windows free of signs of deterioration or missing or broken out panes?
Ceiling Condition Is the ceiling sound and free from hazardous defects?
Wall Condition Are the walls sound and free from hazardous defects?
Floor Condition Is the floor sound and free from hazardous defects?
Lead-Based Paint 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 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 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 Is there a kitchen sink that works with hot and cold running water?
Space for Storage, Preparation, and Serving Serving of Food Is there space to store, prepare, and serve food?

Bathroom

Bathroom Present (See description) Is there a bathroom?
Electricity Is there at least one permanently installed light fixture?
Electrical Hazards Is the bathroom free from electrical hazards?
Security Are all windows and doors that are accessible from the outside lockable?
Window Condition Are all windows free of signs of deterioration or missing or broken out panes?
Ceiling Condition Is the ceiling sound and free from hazardous defects?
Wall Condition Are the walls sound and free from hazardous defects?
Floor Condition Is the floor sound and free from hazardous defects?
Lead-Based Paint 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 Is there a working, permanently installed washbasin with hot and cold running water in the unit?
Tub or Shower Is there a working tub or shower with hot and cold running water in the unit?
Ventilation Are there operable windows or a working vent system?

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
- 1
- 2
- 3
- 4
- 5
- 6
Electricity/Illumination 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 Is the room free from electrical hazards?
Security Are all windows and doors that are accessible from the outside lockable?
Window Condition 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 Is the ceiling sound and free from hazardous defects
Wall Condition Are the walls sound and free from hazardous defects?
Floor Condition Is the floor sound and free from hazardous defects?
Lead-Based Paint 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 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 Are all windows and doors that are accessible from the outside lockable?
Electrical Hazards Are all these rooms free from electrical hazards?
Other Potentially Hazardous Features Are all of these rooms free of any other potentially hazardous features? 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 Is the foundation sound and free from hazards?
Condition of Stairs, Rails, and Porches Are all the exterior stairs, rails, and porches sound and free from hazards?
Condition of Roof and Gutters Are the roof, gutters, and downspouts sound and free from hazards?
Condition of Exterior Surfaces Are exterior surfaces sound and free from hazards?
Condition of Chimney Is the chimney sound and free from hazards?
Lead-Based Paint: Exterior Surfaces 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 If the unit is a manufactured home, is it properly placed and tied down? If not a manufactured home, type in notes as "Not Applicable."

Heating and Plumbing

Adequacy of Heating Equipment Is the heating equipment capable of providing adequate heat (either directly or indirectly) to all rooms used for a living?
Safety of Heating Equipment Is the unit free from unvented fuel-burning space heaters or any other types of unsafe heating conditions?
Ventilation and Adequacy of Cooling Does the unit have adequate ventilation and cooling by means of openable windows or a working cooling system?
Water Heater Is the water heater located, equipped, and installed in a safe manner?
Water Supply Is the unit served by an approvable public or private sanitary water supply?
Plumbing Is plumbing free from major leaks or corrosion that causes serious and persistent levels of rust or contamination of the drinking water?
Sewer Connection 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 Can the unit be entered without having to go through another unit?
Exits Is there an acceptable fire exit from this building that is not blocked?
Evidence of Infestation Is the unit free from rats or severe infestation by mice or vermin?
Garbage and Debris Is the unit free from heavy accumulation of garbage or debris inside and outside?
Refuse Disposal 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 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 Is the interior of the unit free from any other hazard not specifically identified previously?
Elevators 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 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 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: Has certification been completed, and received by the PHA?