APPENDIX 15

SAMPLE FORMS: PROPERTY INSPECTION FORMS

SAMPLE FORM: PROPERTY INSPECTION FORM

A. GENERAL INFORMATION

Date of
Inspection:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Address of Inspected Unit:
Street:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

City:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ County:\_\_\_\_\_\_\_\_\_\_\_\_
State:\_\_\_\_\_\_\_

Zip:\_\_\_\_\_\_

Name of Family
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Current Address of Family:

Street:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

City:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
County:\_\_\_\_\_\_\_\_\_\_\_\_\_\_ State:\_\_\_\_\_\_\_\_

Zip:\_\_\_\_\_

Current Telephone of
Family:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

B. HOW TO FILL OUT THIS CHECKLIST

Proceed through the inspection as follows:

Area Checklist Category

. room by room 1. Living Room, 2. Kitchen, 3. Bathroom,

4\. All Other Rooms Used for Living,

5\. All Secondary Rooms Not Used for

Living

. basement or utility 6. Heating and Plumbing

room

. outside 7. Building Exterior

. overall 8. General Health and Safety

Each part of the checklist will be accompanied by an explanation of

the item to be inspected.

Important: For each item numbered on the checklist, check one

box only (e.g., check one box only for item 1.4

\"Security,\" in the Living Room).

In the space to the right of the description of the item, if the

decision on the item is: \"Fail\" write what repairs are necessary.

Also, if \"Pass\" but there are additional code items or items not

consistent with rehab standards or area codes, write these in the

space to the right.

\-- SAMPLE \-- Appendix 15

A-15.1

1\. LIVING ROOM For each Item numbered, check one box

only.

DECISION

Yes, No,

Item \# Description PASS FAIL Repairs Required

1.1 LIVING ROOM PRESENT

Is there a living room?

1.2 ELECTRICITY

Are there at least two working outlets

or one working outlet and one working

light fixture\'?

1.3 ELECTRICAL HAZARDS

Is the room free from electrical hazards?

1.4 SECURITY

Are all windows and doors that are

accessible from the outside lockable?

1.5 WINDOW CONDITION

Is there at least one window, and

are all windows free of signs of

severe deterioration or missing

or broken out panes?

1.6 CEILING CONDITION

Is the ceiling sound and free

from hazardous defects?

1.7 WALL CONDITION

Are the walls sound and free

from hazardous defects?

1.8 FLOOR CONDITION

Is the floor sound and free

from hazardous defects?

1.9 LEAD PAINT

Are all interior surfaces either

free of cracking, scaling, peeling,

chipping, and loose paint or adequately

treated and covered to prevent

exposure of the occupants to lead-based

paint hazards?

1.10 WEATHERSTRIPPING

Is weatherstripping present and in good

condition on all windows and exterior doors?

1.11 OTHER

1.12 OTHER

Notes: (Give Item #)

\-- SAMPLE \-- Appendix 15

A-15.2

2\. KITCHEN For each Item

numbered, check one box only.

DECISION

Yes, No,

Item \# Description PASS FAIL Repairs Required

2.1 KITCHEN AREA PRESENT

Is there a kitchen?

2.2 ELECTRICITY

Is there at least one working electric

outlet and one working, permanently

installed light fixture?

2.3 ELECTRICAL HAZARDS

Is the kitchen free from electrical hazards?

2.4 SECURITY

Are all windows and doors that are accessible

from the outside lockable?

2.5 WINDOW CONDITION

Are all windows free of signs of

deterioration or missing or broken out panes?

2.6 CEILING CONDITION

Is the ceiling sound and free from hazardous defects?

2.7 WALL CONDITION

Are the walls sound and free from hazardous defects?

2.8 FLOOR CONDITION

Is the floor sound and free from hazardous defects?

2.9 LEAD PAINT

Are all interior surfaces either free of cracking,

scaling, peeling, chipping, and loose paint or

adequately treated and covered to prevent exposure

of the occupants to lead-based paint hazards?

2.10 STOVE OR RANGE WITH OVEN

Is there a working oven, and a stove (or range)

with top burners that work?

2.11 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?

2.12 SINK

Is there a kitchen sink that works with hot

and cold running water?

2.13 SPACE FOR STORAGE AND PREPARATION OF FOOD

Is there a space to store and prepare food?

2.14 WEATHERSTRIPPING

Is weatherstripping present and in good condition

on all windows and exterior doors?

2.15 OTHER

2.16 OTHER

Notes: (Give Item #)

\-- SAMPLE \-- Appendix 15

A-15.3

3\. BATHROOM For each item numbered, check

one box only.

DECISION

Yes No.

Item Description PAST FAIL Repairs Required

3.1 BATHROOM PRESENT (see description)

Is there a bathroom?

3.2 ELECTRICITY

Is there at least one permanently installed light fixture?

3.3 ELECTRICAL HAZARDS

Is the bathroom free from electrical hazards?

3.4 SECURITY

Are all windows and doors that are accessible

from the outside lockable?

3 .5 WINDOW CONDITION

Are all windows free of signs of deterioration or

missing or broken out panes?

3.6 CEILING CONDITION

Is the ceiling sound and free from hazardous defects?

3.7 WALL CONDITION

Are the walls sound and free from hazardous defects?

3.8 FLOOR CONDITION

Is the floor sound and free from hazardous defects?

3.9 LEAD PAINT

Are all interior surfaces either free of cracking,

scaling, peeling, chipping, and loose paint or

adequately treated and covered to prevent exposure

of the occupants to lead-based paint hazards?

3.10 FLUSH TOILET IN ENCLOSED ROOM IN UNIT

Is there a working toilet in the unit for exclusive

private use of the tenant?

3.11 FIXED WASH BASIN OR LAVATORY IN UNIT

Is there a working,permanently installed wash

basin with hot and cold running water in the unit?

3.12 TUB OR SHOWER IN UNIT

Is there a working tub or shower with hot

and cold running water in the unit?

3.13 VENTILATION

Are there openable windows or a working vent system?

3.14 WEATHERSTRIPPING

Is weatherstripping present and in good condition

on all windows and exterior doors?

3.15 OTHER

3.16 OTHER

Notes: (Give Item #)

\-- SAMPLE \-- Appendix 15

A-15.4

4\. OTHER ROOMS USED FOR LIVING

AND HALLS For each item numbered, check

one box only.

DECISION

Yes, No,

Item Description PASS FAIL Repairs Required

4.1 ROOM CODE and ROOM CODES

ROOM LOCATION: 1 = Bedroom or any other room used for sleeping

(regardless of type of room)

2 = Dining Room, or Dining Area

right/left \_\_\_\_ 3 = Living Room, Family Room, Den, Playroom, TV Room

front/rear \_\_\_\_ 4 = Entrance Halls, Corridors, Halls, Staircases

floor/level \_\_\_\_ 5 = Additional Bathroom

6 = Other

4.2 ELECTRICITY

IF Room Code = 1, are there at least two

working outlets or one working outlet and

one working, permanently installed light

fixture? If Room Code not = 1, is there

a means of illumination?

4.3 ELECTRICAL HAZARDS

Is the room free from electrical hazards?

4.4 SECURITY

Are all windows and doors that are accessible

from the outside lockable?

4.5 WINDOW CONDITION

If Room Code = 1, is there at least one

window? And, regardless of Room Code,

are all windows free of signs of severe

deterioration or missing or broken out panes?

4.6 CEILING CONDITION

Is the ceiling sound and free from hazardous defects?

4.7 WALL CONDITION

Are the walls sound and free from hazardous defects?

4.8 FLOOR CONDITION

Is the floor sound and free from hazardous defects?

4.9 LEAD PAINT

Are all interior surfaces either free of cracking,

scaling, peeling, chipping, and loose paint or

adequately treated and covered to prevent exposure of

the occupants to lead-based paint hazards?

4.10 WEATHERSTRIPPING

Is weatherstripping present and in good

condition on all windows and exterior doors?

4.11 OTHER

4.12 OTHER

Notes: (Give Item #)

\-- SAMPLE \-- Appendix 15

A-15.5

5\. ALL SECONDARY ROOMS (Rooms not

used for living) For each item numbered, check

one box only.

DECISION

Yes, No,

Item \# Description PASS FAIL

Repairs Required

5.1 NONE \_\_ GO TO PART 6

5.2 SECURITY

Are all windows and doors that are

accessible from the outside lockable

in each room?

5.3 ELECTRICAL HAZARDS

Are all these rooms free from electrical hazards?

5.4 OTHER POTENTIALLY HAZARDOUS FEATURES IN ANY OF THESE ROOMS

Are all of these rooms free of any other

potentially hazardous features? For each room

with an other potentially hazardous feature,

explain hazard and means of control of interior access to room.

5.5 OTHER

5.6 OTHER

Notes: (Give Item #)

\-- SAMPLE \-- Appendix 15

A-15.6

6\. BUILDING EXTERIOR For each item numbered, check one box only.

DECISION

Yes, No,

Item \# Description PASS FAIL Repairs Required

6.1 CONDITION OF FOUNDATION

Is the foundation sound and free from hazards?

6.2 CONDITION OF STAIRS, RAILS, AND PORCHES

Are all the exterior stairs, rails and

porches sound and free from hazards?

6.3 CONDITION OF ROOF AND GUTTERS

Are the roof, gutters and downspouts

sound and free from hazards?

6.4 CONDITION OF EXTERIOR SURFACES

Are exterior surfaces sound and free from hazards?

6.5 CONDITION OF CHIMNEY

Is the chimney sound and free from hazards?

6.6 LEAD PAINT: EXTERIOR SURFACES

Are all exterior surfaces which are

accessible to children under seven years

of age free of cracking, scaling, peeling,

chipping, and loose paint or adequately

treated or covered to prevent exposure of

such children to lead-based paint hazards?

6.7 MOBILE HOMES: TIE DOWNS

If the unit is a mobile home, it is properly

placed and tied down? If not a mobile home,

check \"Not Applicable.\"

6.8 MOBILE HOMES: SMOKE DETECTORS

If unit is a mobile home, does it

have at least one smoke detector

in working condition? If not a mobile

home, check \"Not Applicable.\"

6.9 CAULKING

Are all fixed joints including frames

around doors and windows, areas around

all holes for pipes, ducts, water

faucets or electric conduits, and other

areas may allow unwanted air flow

appropriately caulked.

6.10 OTHER

6.11 OTHER

Notes: (Give Item #)

\-- SAMPLE \-- Appendix 15

A-15.7

7\. HEATING, PLUMBING AND

INSULATION For each item numbered, check one box only.

DECISION

Yes, No,

Item \# Description PASS FAIL Repairs Required

7.1 ADEQUACY OF HEATING EQUIPMENT

a\. Is the heating equipment

capable of providing adequate

heat (either directly or

indirectly) to all rooms

used for living?

b\. Is the heating equipment

oversized by more than 15%?

c\. Are pipes and ducts located

in unconditioned space insulated?

7.2 SAFETY OF HEATING EQUIPMENT

Is the unit free from unvented fuel burning

space heaters or any other types of unsafe

heating conditions?

7.3 VENTILATION AND ADEQUACY OF COOLING

Does this unit have adequate ventilation

and cooling by means of operable windows

or a working cooling system?

7.4 NOT WATER HEATER

Is hot water heater located, equipped,

and installed in a safe manner?

7.5 WATER SUPPLY

Is the unit served by an approvable

public or private sanitary water supply?

7.6 PLUMBING

Is plumbing free from major leaks or

corrosion that causes serious and

persistent levels of rust or contamination

of the drinking water?

7.7 SEWER CONNECTION

Is plumbing corrected to an approvable

public or private disposal system, and

is it free from sewer back-up?

7.8 INSULATION

Are the attic and walls appropriately

initiated for regional conditions?

7.9 OTHER

7.10 OTHER

Notes: (Give Item #)

\-- SAMPLE \-- Appendix 15

A-15.8

8\. GENERAL HEALTH AND SAFETY For each item numbered, check one box
only.

DECISION

Yes, No,

Item \# Description PASS FAIL Repairs Required

8.1 ACCESS TO UNIT

Can the unit be entered without

having to go through another unit?

8.2 EXITS

Is there an acceptable fire exit from this

building that is not blocked?

8.3 EVIDENCE OF INFESTATION

Is the unit free from rats or

severe infestation by mice or vermin?

8.4 GARBAGE AND DEBRIS

Is the unit free from heavy accumulation

of garbage or debris inside or outside?

8.5 REFUSE DISPOSAL

Are there adequate covered facilities for

temporary storage and disposal of food wastes,

and are they approvable by a local agency?

8.6 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?

8.7 OTHER INTERIOR HAZARDS

Is the interior of the unit free

from any other hazards not specifically

identified previously?

8.8 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?

8.9 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?

8.10 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?

Notes: (Give Item #)

\--SAMPLE \-- Appendix 15

A-15.9

8\. GENERAL HEALTH AND SAFETY

(cont\'d.) For each item numbered, check

one box only.

DECISION

Yes, No,

Item Description PASS FAIL Repairs Required

8.11 LEAD PAINT: OWNER CERTIFICATION

If the owner of the unit is required to treat or

cover any interior or exterior surfaces, has the

certification of compliance been obtained? If

owner was not required to treat surfaces,

check \"Not Applicable.\"

8.12 OTHER

8.13 OTHER

Notes: (Give Item #)

\-- SAMPLE \-- Appendix 15

A-15.10