Unfit Housing, Squalor & Hoarding Assessment Form

• Site conducted

  Select

• Date

  Date

• Officer

• Name

• Address
  Address

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• Accessibility - % of floor space inaccessible for walking or use

  0%-29%

  29%-59%

  60%-89%

  89%-100%

• Accumulation of Refuse or Garbage

  None

  Little

  Moderate

  A Lot

• Accumulation of Items of Little Obvious Value - In general, is there evidence of accumulation of items that most people would consider useless or should be thrown away?

  None

  Little

  Moderate

  A Lot

• Cleanliness of Floors and Carpet

  Clean

  Mildly Dirty

  Very Dirty

  Filthy

• Cleanliness of Walls, Furniture Surfaces and Window Sills

  Clean

  Mildly Dirty

  Very Dirty

  Filthy

• Cleanliness of Bathroom and Toilet

  Clean

  Mildly Dirty

  Very Dirty

  Filthy

• Kitchen and Food - Oven, surfaces and cupboards clean? Amount of refuse and garbage over surfaces or floor? Perished food?

  Clean

  Mildly Dirty

  Very Dirty

  Filthy

• Odour

  None

  Unpleasant

  Moderate

  Unbearable

• Vermin

  None

  Few

  Moderate

  Infestation

• Sleeping Area

  Clean

  Mildly Unclean

  Moderate

  Unbearable

Essential Living Conditions

• Running water to kitchen, bathroom

  Acceptable

  Unacceptable

  N/A

• Electricity connected, working and appears safe

  Acceptable

  Unacceptable

  N/A

• Gas connected (if applicable), working and appears safe

  Acceptable

  Unacceptable

  N/A

• Wastewater System operational

  Acceptable

  Unacceptable

  N/A

• Dwelling appears Structurally Safe

  Acceptable

  Unacceptable

  N/A

• Health Risk to Neighbouring Residents

  Acceptable

  Unacceptable

  N/A

• Damaged Asbestos

  Acceptable

  Unacceptable

  N/A

• Substantial Mould

  Acceptable

  Unacceptable

  N/A

External Agencies to Contact

• Children at risk from living conditions – Department of Child Protection

  Acceptable

  Unacceptable

  N/A

• Animals Cared for - RSPCA

  Acceptable

  Unacceptable

  N/A

• Venerable Persons Cared for – Various Agencies

  Acceptable

  Unacceptable

  N/A

• High Fire Risk - DEFES

  Acceptable

  Unacceptable

  N/A

Completion

• Notes

• Name and Signature

  Sign