Nature of the Call

Call Findings & Results

Owner/Agent Name

OwnerAgent Street Address

OwnerAgent City, State & Zip

Owner/Agent Phone

Tenant Name

Tenant Phone



Were the premises made UNSAFE/UNFIT?

How many occupants/tenants were dislocated from the building/unit?

Did the occupant(s)/tenants have a place to go?

Did you provide relocation slip(s)?

Was the building secured with a city padlock?

Actions Taken

Has this information been entered into Department Computer System?

Please note that this checklist is a hypothetical example and provides basic information only. It is not intended to take the place of, among other things, workplace, health and safety advice; medical advice, diagnosis, or treatment; or other applicable laws. You should also seek your own professional advice to determine if the use of such checklist is permissible in your workplace or jurisdiction.