Client \# \_\_\_\_\_\_\_\_\_\_\_\_\_\_

# Housing Quality Standards (HQS) 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                                 |
+-------------------------+--------------------------------------------+
| Outside                 | 6\. Building Exterior                      |
+-------------------------+--------------------------------------------+
| Basement or Utility     | 7\. Heating and Plumbing                   |
| Room                    |                                            |
+-------------------------+--------------------------------------------+
| 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.

+-----+---------------------------+----+---+--------------------------+
| *   |                           | *  |   |                          |
| *1. |                           | *F |   |                          |
| LIV |                           | or |   |                          |
| ING |                           | ea |   |                          |
| ROO |                           | ch |   |                          |
| M** |                           | it |   |                          |
|     |                           | em |   |                          |
|     |                           | n  |   |                          |
|     |                           | um |   |                          |
|     |                           | be |   |                          |
|     |                           | re |   |                          |
|     |                           | d, |   |                          |
|     |                           | c  |   |                          |
|     |                           | he |   |                          |
|     |                           | ck |   |                          |
|     |                           | o  |   |                          |
|     |                           | ne |   |                          |
|     |                           | b  |   |                          |
|     |                           | ox |   |                          |
|     |                           | o  |   |                          |
|     |                           | nl |   |                          |
|     |                           | y. |   |                          |
|     |                           | ** |   |                          |
+=====+===========================+====+===+==========================+
|     |                           | DE |   |                          |
|     |                           | CI |   |                          |
|     |                           | SI |   |                          |
|     |                           | ON |   |                          |
+-----+---------------------------+----+---+--------------------------+
| I   | Description               | Ye | N | Repairs Required         |
| tem |                           | s, | o |                          |
| \#  |                           | PA | , |                          |
|     |                           | SS | F |                          |
|     |                           |    | A |                          |
|     |                           |    | I |                          |
|     |                           |    | L |                          |
+-----+---------------------------+----+---+--------------------------+
| *   | **LIVING ROOM PRESENT**   |    |   |                          |
| *1. |                           |    |   |                          |
| 1** | Is there a living room?   |    |   |                          |
+-----+---------------------------+----+---+--------------------------+
| *   | **ELECTRICITY**           |    |   |                          |
| *1. |                           |    |   |                          |
| 2** | Are there at least two    |    |   |                          |
|     | working outlets or one    |    |   |                          |
|     | working outlet and one    |    |   |                          |
|     | working light fixture?    |    |   |                          |
+-----+---------------------------+----+---+--------------------------+
| *   | **ELECTRICAL HAZARDS**    |    |   |                          |
| *1. |                           |    |   |                          |
| 3** | Is the room free from     |    |   |                          |
|     | electrical hazards?       |    |   |                          |
+-----+---------------------------+----+---+--------------------------+
| *   | **SECURITY**              |    |   |                          |
| *1. |                           |    |   |                          |
| 4** | Are all windows and doors |    |   |                          |
|     | that are accessible from  |    |   |                          |
|     | the outside lockable?     |    |   |                          |
+-----+---------------------------+----+---+--------------------------+
| *   | **WINDOW CONDITION**      |    |   |                          |
| *1. |                           |    |   |                          |
| 5** | Is there at least one     |    |   |                          |
|     | window, and are all       |    |   |                          |
|     | windows free of signs of  |    |   |                          |
|     | severe deterioration or   |    |   |                          |
|     | missing or broken out     |    |   |                          |
|     | panes?                    |    |   |                          |
+-----+---------------------------+----+---+--------------------------+
| *   | **CEILING CONDITION**     |    |   |                          |
| *1. |                           |    |   |                          |
| 6** | Is the ceiling sound and  |    |   |                          |
|     | free from hazardous       |    |   |                          |
|     | defects?                  |    |   |                          |
+-----+---------------------------+----+---+--------------------------+
| *   | **WALL CONDITION**        |    |   |                          |
| *1. |                           |    |   |                          |
| 7** | Are the walls sound and   |    |   |                          |
|     | free from hazardous       |    |   |                          |
|     | defects?                  |    |   |                          |
+-----+---------------------------+----+---+--------------------------+
| *   | **FLOOR CONDITION**       |    |   |                          |
| *1. |                           |    |   |                          |
| 8** | Is the floor sound and    |    |   |                          |
|     | free from hazardous       |    |   |                          |
|     | defects?                  |    |   |                          |
+-----+---------------------------+----+---+--------------------------+
| *   | **LEAD PAINT**            |    |   |                          |
| *1. |                           |    |   |                          |
| 9** | 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?                  |    |   |                          |
+-----+---------------------------+----+---+--------------------------+
| **  | **WEATHER STRIPPING**     |    |   |                          |
| 1.1 |                           |    |   |                          |
| 0** | Is weather stripping      |    |   |                          |
|     | present and in good       |    |   |                          |
|     | condition on all windows  |    |   |                          |
|     | and exterior doors?       |    |   |                          |
+-----+---------------------------+----+---+--------------------------+
| **  | **OTHER**                 |    |   |                          |
| 1.1 |                           |    |   |                          |
| 1** |                           |    |   |                          |
+-----+---------------------------+----+---+--------------------------+
| **  | **OTHER**                 |    |   |                          |
| 1.1 |                           |    |   |                          |
| 2** |                           |    |   |                          |
+-----+---------------------------+----+---+--------------------------+

Notes: (Give Item #)

+-----+---------------------------+----+---+--------------------------+
| *   |                           | *  |   |                          |
| *2. |                           | *F |   |                          |
| KIT |                           | or |   |                          |
| CHE |                           | ea |   |                          |
| N** |                           | ch |   |                          |
|     |                           | it |   |                          |
|     |                           | em |   |                          |
|     |                           | n  |   |                          |
|     |                           | um |   |                          |
|     |                           | be |   |                          |
|     |                           | re |   |                          |
|     |                           | d, |   |                          |
|     |                           | c  |   |                          |
|     |                           | he |   |                          |
|     |                           | ck |   |                          |
|     |                           | o  |   |                          |
|     |                           | ne |   |                          |
|     |                           | b  |   |                          |
|     |                           | ox |   |                          |
|     |                           | o  |   |                          |
|     |                           | nl |   |                          |
|     |                           | y. |   |                          |
|     |                           | ** |   |                          |
+=====+===========================+====+===+==========================+
|     |                           | DE |   |                          |
|     |                           | CI |   |                          |
|     |                           | SI |   |                          |
|     |                           | ON |   |                          |
+-----+---------------------------+----+---+--------------------------+
| I   | Description               | Ye | N | Repairs Required         |
| tem |                           | s, | o |                          |
| \#  |                           |    | , |                          |
|     |                           | PA |   |                          |
|     |                           | SS | F |                          |
|     |                           |    | A |                          |
|     |                           |    | I |                          |
|     |                           |    | L |                          |
+-----+---------------------------+----+---+--------------------------+
| *   | **KITCHEN AREA PRESENT**  |    |   |                          |
| *2. |                           |    |   |                          |
| 1** | Is there a kitchen?       |    |   |                          |
+-----+---------------------------+----+---+--------------------------+
| *   | **ELECTRICITY**           |    |   |                          |
| *2. |                           |    |   |                          |
| 2** | Is there at least *one*   |    |   |                          |
|     | working electric outlet   |    |   |                          |
|     | and *one* working,        |    |   |                          |
|     | permanently installed     |    |   |                          |
|     | light fixture?            |    |   |                          |
+-----+---------------------------+----+---+--------------------------+
| *   | **ELECTRICAL HAZARDS**    |    |   |                          |
| *2. |                           |    |   |                          |
| 3** | Is the kitchen free from  |    |   |                          |
|     | electrical hazards?       |    |   |                          |
+-----+---------------------------+----+---+--------------------------+
| *   | **SECURITY**              |    |   |                          |
| *2. |                           |    |   |                          |
| 4** | Are *all* windows and     |    |   |                          |
|     | doors that are accessible |    |   |                          |
|     | from the outside          |    |   |                          |
|     | lockable?                 |    |   |                          |
+-----+---------------------------+----+---+--------------------------+
| *   | **WINDOW CONDITION**      |    |   |                          |
| *2. |                           |    |   |                          |
| 5** | Are all windows free of   |    |   |                          |
|     | signs of deterioration or |    |   |                          |
|     | missing or broken out     |    |   |                          |
|     | panes?                    |    |   |                          |
+-----+---------------------------+----+---+--------------------------+
| *   | **CEILING CONDITION**     |    |   |                          |
| *2. |                           |    |   |                          |
| 6** | Is the ceiling sound and  |    |   |                          |
|     | free from hazardous       |    |   |                          |
|     | defects?                  |    |   |                          |
+-----+---------------------------+----+---+--------------------------+
| *   | **WALL CONDITION**        |    |   |                          |
| *2. |                           |    |   |                          |
| 7** | Are the walls sound and   |    |   |                          |
|     | free from hazardous       |    |   |                          |
|     | defects?                  |    |   |                          |
+-----+---------------------------+----+---+--------------------------+
| *   | **FLOOR CONDITION**       |    |   |                          |
| *2. |                           |    |   |                          |
| 8** | Is the floor sound and    |    |   |                          |
|     | free from hazardous       |    |   |                          |
|     | defects?                  |    |   |                          |
+-----+---------------------------+----+---+--------------------------+
| *   | **LEAD PAINT**            |    |   |                          |
| *2. |                           |    |   |                          |
| 9** | 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?                  |    |   |                          |
+-----+---------------------------+----+---+--------------------------+
| **  | **STOVE OR RANGE WITH     |    |   |                          |
| 2.1 | OVEN**                    |    |   |                          |
| 0** |                           |    |   |                          |
|     | Is there a working oven   |    |   |                          |
|     | and a stove (or range)    |    |   |                          |
|     | with top burners that     |    |   |                          |
|     | work?                     |    |   |                          |
+-----+---------------------------+----+---+--------------------------+
| **  | **REFRIGERATOR**          |    |   |                          |
| 2.1 |                           |    |   |                          |
| 1** | 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**                  |    |   |                          |
| 2.1 |                           |    |   |                          |
| 2** | Is there a kitchen sink   |    |   |                          |
|     | that works with hot and   |    |   |                          |
|     | cold running water?       |    |   |                          |
+-----+---------------------------+----+---+--------------------------+
| **  | **SPACE FOR STORAGE AND   |    |   |                          |
| 2.1 | PREPARATION OF FOOD**     |    |   |                          |
| 3** |                           |    |   |                          |
|     | Is there space to store   |    |   |                          |
|     | and prepare food?         |    |   |                          |
+-----+---------------------------+----+---+--------------------------+
| **  | **WEATHER STRIPPING**     |    |   |                          |
| 2.1 |                           |    |   |                          |
| 4** | Is weather stripping      |    |   |                          |
|     | present and in good       |    |   |                          |
|     | condition on all windows  |    |   |                          |
|     | and exterior doors?       |    |   |                          |
+-----+---------------------------+----+---+--------------------------+
| **  | ###### OTHER              |    |   |                          |
| 2.1 |                           |    |   |                          |
| 5** |                           |    |   |                          |
+-----+---------------------------+----+---+--------------------------+
| **  | ###### OTHER              |    |   |                          |
| 2.1 |                           |    |   |                          |
| 6** |                           |    |   |                          |
+-----+---------------------------+----+---+--------------------------+

Notes: (Give Item #)

+-----+---------------------------+----+---+--------------------------+
| *   |                           | *  |   |                          |
| *3. |                           | *F |   |                          |
| B   |                           | or |   |                          |
| ATH |                           | ea |   |                          |
| ROO |                           | ch |   |                          |
| M** |                           | it |   |                          |
|     |                           | em |   |                          |
|     |                           | n  |   |                          |
|     |                           | um |   |                          |
|     |                           | be |   |                          |
|     |                           | re |   |                          |
|     |                           | d, |   |                          |
|     |                           | c  |   |                          |
|     |                           | he |   |                          |
|     |                           | ck |   |                          |
|     |                           | o  |   |                          |
|     |                           | ne |   |                          |
|     |                           | b  |   |                          |
|     |                           | ox |   |                          |
|     |                           | o  |   |                          |
|     |                           | nl |   |                          |
|     |                           | y. |   |                          |
|     |                           | ** |   |                          |
+=====+===========================+====+===+==========================+
|     |                           | DE |   |                          |
|     |                           | CI |   |                          |
|     |                           | SI |   |                          |
|     |                           | ON |   |                          |
+-----+---------------------------+----+---+--------------------------+
| I   | Description               | Ye | N | Repairs Required         |
| tem |                           | s, | o |                          |
| \#  |                           |    | , |                          |
|     |                           | PA |   |                          |
|     |                           | SS | F |                          |
|     |                           |    | A |                          |
|     |                           |    | I |                          |
|     |                           |    | L |                          |
+-----+---------------------------+----+---+--------------------------+
| *   | **BATHROOM (see           |    |   |                          |
| *3. | description)**            |    |   |                          |
| 1** |                           |    |   |                          |
|     | Is there a bathroom?      |    |   |                          |
+-----+---------------------------+----+---+--------------------------+
| *   | **ELECTRICITY**           |    |   |                          |
| *3. |                           |    |   |                          |
| 2** | Is there at least *one*   |    |   |                          |
|     | permanently installed     |    |   |                          |
|     | light fixture?            |    |   |                          |
+-----+---------------------------+----+---+--------------------------+
| *   | **ELECTRICAL HAZARDS**    |    |   |                          |
| *3. |                           |    |   |                          |
| 3** | Is the bathroom free from |    |   |                          |
|     | electrical hazards?       |    |   |                          |
+-----+---------------------------+----+---+--------------------------+
| *   | **SECURITY**              |    |   |                          |
| *3. |                           |    |   |                          |
| 4** | Are *all* windows and     |    |   |                          |
|     | doors that are accessible |    |   |                          |
|     | from the outside          |    |   |                          |
|     | lockable?                 |    |   |                          |
+-----+---------------------------+----+---+--------------------------+
| *   | **WINDOW CONDITION**      |    |   |                          |
| *3. |                           |    |   |                          |
| 5** | Are all windows free of   |    |   |                          |
|     | signs of deterioration or |    |   |                          |
|     | missing or broken out     |    |   |                          |
|     | panes?                    |    |   |                          |
+-----+---------------------------+----+---+--------------------------+
| *   | **CEILING CONDITION**     |    |   |                          |
| *3. |                           |    |   |                          |
| 6** | Is the ceiling sound and  |    |   |                          |
|     | free from hazardous       |    |   |                          |
|     | defects?                  |    |   |                          |
+-----+---------------------------+----+---+--------------------------+
| *   | **WALL CONDITION**        |    |   |                          |
| *3. |                           |    |   |                          |
| 7** | Are the walls sound and   |    |   |                          |
|     | free from hazardous       |    |   |                          |
|     | defects?                  |    |   |                          |
+-----+---------------------------+----+---+--------------------------+
| *   | **FLOOR CONDITION**       |    |   |                          |
| *3. |                           |    |   |                          |
| 8** | Is the floor sound and    |    |   |                          |
|     | free from hazardous       |    |   |                          |
|     | defects?                  |    |   |                          |
+-----+---------------------------+----+---+--------------------------+
| *   | **LEAD PAINT**            |    |   |                          |
| *3. |                           |    |   |                          |
| 9** | 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?                  |    |   |                          |
+-----+---------------------------+----+---+--------------------------+
| **  | **FLUSH TOILET IN         |    |   |                          |
| 3.1 | ENCLOSED ROOM IN UNIT**   |    |   |                          |
| 0** |                           |    |   |                          |
|     | Is there a working toilet |    |   |                          |
|     | in the unit for exclusive |    |   |                          |
|     | private use of the        |    |   |                          |
|     | tenant?                   |    |   |                          |
+-----+---------------------------+----+---+--------------------------+
| **  | **FIXED WASH BASIN OR     |    |   |                          |
| 3.1 | LAVATORY IN UNIT**        |    |   |                          |
| 1** |                           |    |   |                          |
|     | Is there a working,       |    |   |                          |
|     | permanently installed     |    |   |                          |
|     | wash basin with hot and   |    |   |                          |
|     | cold running water in the |    |   |                          |
|     | unit?                     |    |   |                          |
+-----+---------------------------+----+---+--------------------------+
| **  | **TUB OR SHOWER IN UNIT** |    |   |                          |
| 3.1 |                           |    |   |                          |
| 2** | Is there a working tub or |    |   |                          |
|     | shower with hot and cold  |    |   |                          |
|     | running water in the      |    |   |                          |
|     | unit?                     |    |   |                          |
+-----+---------------------------+----+---+--------------------------+
| **  | **VENTILATION**           |    |   |                          |
| 3.1 |                           |    |   |                          |
| 3** | Are there operable        |    |   |                          |
|     | windows or a working vent |    |   |                          |
|     | system?                   |    |   |                          |
+-----+---------------------------+----+---+--------------------------+
| **  | **WEATHER STRIPPING**     |    |   |                          |
| 3.1 |                           |    |   |                          |
| 4** | Is weather stripping      |    |   |                          |
|     | present and in good       |    |   |                          |
|     | condition on all windows  |    |   |                          |
|     | and exterior doors?       |    |   |                          |
+-----+---------------------------+----+---+--------------------------+
| **  | **OTHER**                 |    |   |                          |
| 3.1 |                           |    |   |                          |
| 5** |                           |    |   |                          |
+-----+---------------------------+----+---+--------------------------+
| **  | **OTHER**                 |    |   |                          |
| 3.1 |                           |    |   |                          |
| 6** |                           |    |   |                          |
+-----+---------------------------+----+---+--------------------------+

Notes: (Give Item #)

+-----+---------------------------+----+----+-------------------------+
| *   |                           | *  |    |                         |
| *4. |                           | *F |    |                         |
| OT  |                           | or |    |                         |
| HER |                           | ea |    |                         |
| RO  |                           | ch |    |                         |
| OMS |                           | it |    |                         |
| U   |                           | em |    |                         |
| SED |                           | n  |    |                         |
| FOR |                           | um |    |                         |
| LIV |                           | be |    |                         |
| ING |                           | re |    |                         |
| AND |                           | d, |    |                         |
| H   |                           | c  |    |                         |
| ALL |                           | he |    |                         |
| S** |                           | ck |    |                         |
|     |                           | o  |    |                         |
|     |                           | ne |    |                         |
|     |                           | b  |    |                         |
|     |                           | ox |    |                         |
|     |                           | o  |    |                         |
|     |                           | nl |    |                         |
|     |                           | y. |    |                         |
|     |                           | ** |    |                         |
+=====+===========================+====+====+=========================+
|     |                           | DE |    |                         |
|     |                           | CI |    |                         |
|     |                           | SI |    |                         |
|     |                           | ON |    |                         |
+-----+---------------------------+----+----+-------------------------+
| I   | Description               | Ye | N  | Repairs Required        |
| tem |                           | s, | o, |                         |
| \#  |                           | PA | FA |                         |
|     |                           | SS | IL |                         |
+-----+---------------------------+----+----+-------------------------+
| *   | **ROOM CODE and**         | RO |    |                         |
| *4. |                           | OM |    |                         |
| 1** | **ROOM LOCATION:**        | C  |    |                         |
|     |                           | OD |    |                         |
|     | right/left                | ES |    |                         |
|     | \_\_\_\_\_\_\_\_\_\_      |    |    |                         |
|     |                           | 1  |    |                         |
|     | front/rear                | =  |    |                         |
|     | \_\_\_\_\_\_\_\_\_\_      | B  |    |                         |
|     |                           | ed |    |                         |
|     | floor level               | ro |    |                         |
|     | \_\_\_\_\_\_\_\_\_\_      | om |    |                         |
|     |                           | or |    |                         |
|     |                           | a  |    |                         |
|     |                           | ny |    |                         |
|     |                           | o  |    |                         |
|     |                           | th |    |                         |
|     |                           | er |    |                         |
|     |                           | ro |    |                         |
|     |                           | om |    |                         |
|     |                           | us |    |                         |
|     |                           | ed |    |                         |
|     |                           | f  |    |                         |
|     |                           | or |    |                         |
|     |                           | sl |    |                         |
|     |                           | ee |    |                         |
|     |                           | pi |    |                         |
|     |                           | ng |    |                         |
|     |                           | (  |    |                         |
|     |                           | re |    |                         |
|     |                           | ga |    |                         |
|     |                           | rd |    |                         |
|     |                           | le |    |                         |
|     |                           | ss |    |                         |
|     |                           | of |    |                         |
|     |                           | ty |    |                         |
|     |                           | pe |    |                         |
|     |                           | of |    |                         |
|     |                           | r  |    |                         |
|     |                           | oo |    |                         |
|     |                           | m) |    |                         |
|     |                           |    |    |                         |
|     |                           | 2  |    |                         |
|     |                           | =  |    |                         |
|     |                           | Di |    |                         |
|     |                           | ni |    |                         |
|     |                           | ng |    |                         |
|     |                           | R  |    |                         |
|     |                           | oo |    |                         |
|     |                           | m, |    |                         |
|     |                           | or |    |                         |
|     |                           | Di |    |                         |
|     |                           | ni |    |                         |
|     |                           | ng |    |                         |
|     |                           | Ar |    |                         |
|     |                           | ea |    |                         |
|     |                           |    |    |                         |
|     |                           | 3  |    |                         |
|     |                           | =  |    |                         |
|     |                           | Se |    |                         |
|     |                           | co |    |                         |
|     |                           | nd |    |                         |
|     |                           | Li |    |                         |
|     |                           | vi |    |                         |
|     |                           | ng |    |                         |
|     |                           | R  |    |                         |
|     |                           | oo |    |                         |
|     |                           | m, |    |                         |
|     |                           | Fa |    |                         |
|     |                           | mi |    |                         |
|     |                           | ly |    |                         |
|     |                           | R  |    |                         |
|     |                           | oo |    |                         |
|     |                           | m, |    |                         |
|     |                           | De |    |                         |
|     |                           | n, |    |                         |
|     |                           | P  |    |                         |
|     |                           | la |    |                         |
|     |                           | yr |    |                         |
|     |                           | oo |    |                         |
|     |                           | m, |    |                         |
|     |                           | TV |    |                         |
|     |                           | Ro |    |                         |
|     |                           | om |    |                         |
|     |                           |    |    |                         |
|     |                           | 4  |    |                         |
|     |                           | =  |    |                         |
|     |                           | En |    |                         |
|     |                           | tr |    |                         |
|     |                           | an |    |                         |
|     |                           | ce |    |                         |
|     |                           | Ha |    |                         |
|     |                           | ll |    |                         |
|     |                           | s, |    |                         |
|     |                           | Co |    |                         |
|     |                           | rr |    |                         |
|     |                           | id |    |                         |
|     |                           | or |    |                         |
|     |                           | s, |    |                         |
|     |                           | Ha |    |                         |
|     |                           | ll |    |                         |
|     |                           | s, |    |                         |
|     |                           | St |    |                         |
|     |                           | ai |    |                         |
|     |                           | rc |    |                         |
|     |                           | as |    |                         |
|     |                           | es |    |                         |
|     |                           |    |    |                         |
|     |                           | 5  |    |                         |
|     |                           | =  |    |                         |
|     |                           | Ad |    |                         |
|     |                           | di |    |                         |
|     |                           | ti |    |                         |
|     |                           | on |    |                         |
|     |                           | al |    |                         |
|     |                           | Ba |    |                         |
|     |                           | th |    |                         |
|     |                           | ro |    |                         |
|     |                           | om |    |                         |
|     |                           |    |    |                         |
|     |                           | 6  |    |                         |
|     |                           | =  |    |                         |
|     |                           | O  |    |                         |
|     |                           | th |    |                         |
|     |                           | er |    |                         |
+-----+---------------------------+----+----+-------------------------+
| *   | **ELECTRICITY**           |    |    |                         |
| *4. |                           |    |    |                         |
| 2** | 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 does not =   |    |    |                         |
|     | 1, is there a means of    |    |    |                         |
|     | illumination?             |    |    |                         |
+-----+---------------------------+----+----+-------------------------+
| *   | **ELECTRICAL HAZARDS**    |    |    |                         |
| *4. |                           |    |    |                         |
| 3** | Is the room free from     |    |    |                         |
|     | electrical hazards?       |    |    |                         |
+-----+---------------------------+----+----+-------------------------+
| *   | **SECURITY**              |    |    |                         |
| *4. |                           |    |    |                         |
| 4** | Are *all* windows and     |    |    |                         |
|     | doors that are accessible |    |    |                         |
|     | from the outside          |    |    |                         |
|     | lockable?                 |    |    |                         |
+-----+---------------------------+----+----+-------------------------+
| *   | **WINDOW CONDITION**      |    |    |                         |
| *4. |                           |    |    |                         |
| 5** | 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?                    |    |    |                         |
+-----+---------------------------+----+----+-------------------------+
| *   | **CEILING CONDITION**     |    |    |                         |
| *4. |                           |    |    |                         |
| 6** | Is the ceiling sound and  |    |    |                         |
|     | free from hazardous       |    |    |                         |
|     | defects?                  |    |    |                         |
+-----+---------------------------+----+----+-------------------------+
| *   | **WALL CONDITION**        |    |    |                         |
| *4. |                           |    |    |                         |
| 7** | Are the walls sound and   |    |    |                         |
|     | free from hazardous       |    |    |                         |
|     | defects?                  |    |    |                         |
+-----+---------------------------+----+----+-------------------------+
| *   | **FLOOR CONDITION**       |    |    |                         |
| *4. |                           |    |    |                         |
| 8** | Is the floor sound and    |    |    |                         |
|     | free from hazardous       |    |    |                         |
|     | defects?                  |    |    |                         |
+-----+---------------------------+----+----+-------------------------+
| *   | **LEAD PAINT**            |    |    |                         |
| *4. |                           |    |    |                         |
| 9** | 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?                  |    |    |                         |
+-----+---------------------------+----+----+-------------------------+
| **  | **WEATHERSTRIPPING**      |    |    |                         |
| 4.1 |                           |    |    |                         |
| 0** | Is weather stripping      |    |    |                         |
|     | present and in good       |    |    |                         |
|     | condition on all windows  |    |    |                         |
|     | and exterior doors?       |    |    |                         |
+-----+---------------------------+----+----+-------------------------+
| **  | **OTHER**                 |    |    |                         |
| 4.1 |                           |    |    |                         |
| 1** |                           |    |    |                         |
+-----+---------------------------+----+----+-------------------------+
| **  | **OTHER**                 |    |    |                         |
| 4.1 |                           |    |    |                         |
| 2** |                           |    |    |                         |
+-----+---------------------------+----+----+-------------------------+

Notes: (Give Item #)

+-----+---------------------------+----+---+--------------------------+
| *   |                           | *  |   |                          |
| *5. |                           | *F |   |                          |
| ALL |                           | or |   |                          |
| SEC |                           | ea |   |                          |
| OND |                           | ch |   |                          |
| ARY |                           | it |   |                          |
| RO  |                           | em |   |                          |
| OMS |                           | n  |   |                          |
| NOT |                           | um |   |                          |
| U   |                           | be |   |                          |
| SED |                           | re |   |                          |
| FOR |                           | d, |   |                          |
| LI  |                           | c  |   |                          |
| VIN |                           | he |   |                          |
| G** |                           | ck |   |                          |
|     |                           | o  |   |                          |
|     |                           | ne |   |                          |
|     |                           | b  |   |                          |
|     |                           | ox |   |                          |
|     |                           | o  |   |                          |
|     |                           | nl |   |                          |
|     |                           | y. |   |                          |
|     |                           | ** |   |                          |
+=====+===========================+====+===+==========================+
|     |                           | DE |   |                          |
|     |                           | CI |   |                          |
|     |                           | SI |   |                          |
|     |                           | ON |   |                          |
+-----+---------------------------+----+---+--------------------------+
| I   | Description               | Ye | N | Repairs Required         |
| tem |                           | s, | o |                          |
| \#  |                           | PA | , |                          |
|     |                           | SS | F |                          |
|     |                           |    | A |                          |
|     |                           |    | I |                          |
|     |                           |    | L |                          |
+-----+---------------------------+----+---+--------------------------+
| *   | **NONE. GO TO PART 6**    |    |   |                          |
| *5. |                           |    |   |                          |
| 1** |                           |    |   |                          |
+-----+---------------------------+----+---+--------------------------+
| *   | ###### SECURITY           |    |   |                          |
| *5. |                           |    |   |                          |
| 2** | Are *all* windows and     |    |   |                          |
|     | doors that are accessible |    |   |                          |
|     | from the outside lockable |    |   |                          |
|     | in each room?             |    |   |                          |
+-----+---------------------------+----+---+--------------------------+
| *   | **ELECTRICAL HAZARDS**    |    |   |                          |
| *5. |                           |    |   |                          |
| 3** | Are all these rooms free  |    |   |                          |
|     | from electrical hazards?  |    |   |                          |
+-----+---------------------------+----+---+--------------------------+
| *   | **OTHER POTENTIALLY       |    |   |                          |
| *5. | HAZARDOUS FEATURES IN ANY |    |   |                          |
| 4** | 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.  |    |   |                          |
+-----+---------------------------+----+---+--------------------------+
| *   | **OTHER**                 |    |   |                          |
| *5. |                           |    |   |                          |
| 5** |                           |    |   |                          |
+-----+---------------------------+----+---+--------------------------+
| *   | **OTHER**                 |    |   |                          |
| *5. |                           |    |   |                          |
| 6** |                           |    |   |                          |
+-----+---------------------------+----+---+--------------------------+

Notes: (Give Item #)

+-----+----------------------------+-----+---+-----------------------+
| *   |                            | **  |   |                       |
| *6. |                            | For |   |                       |
| BU  |                            | e   |   |                       |
| ILD |                            | ach |   |                       |
| ING |                            | i   |   |                       |
| E   |                            | tem |   |                       |
| XTE |                            | num |   |                       |
| RIO |                            | ber |   |                       |
| R** |                            | ed, |   |                       |
|     |                            | ch  |   |                       |
|     |                            | eck |   |                       |
|     |                            | one |   |                       |
|     |                            | box |   |                       |
|     |                            | o   |   |                       |
|     |                            | nly |   |                       |
|     |                            | .** |   |                       |
+=====+============================+=====+===+=======================+
|     |                            | DE  |   |                       |
|     |                            | CIS |   |                       |
|     |                            | ION |   |                       |
+-----+----------------------------+-----+---+-----------------------+
| I   | Description                | Y   | N | Repairs Required      |
| tem |                            | es, | o |                       |
| \#  |                            | P   | , |                       |
|     |                            | ASS | F |                       |
|     |                            |     | A |                       |
|     |                            |     | I |                       |
|     |                            |     | L |                       |
+-----+----------------------------+-----+---+-----------------------+
| *   | **CONDITION OF             |     |   |                       |
| *6. | FOUNDATION**               |     |   |                       |
| 1** |                            |     |   |                       |
|     | Is the foundation sound    |     |   |                       |
|     | and free from hazards?     |     |   |                       |
+-----+----------------------------+-----+---+-----------------------+
| *   | **CONDITION OF STAIRS,     |     |   |                       |
| *6. | RAILS, AND PORCHES**       |     |   |                       |
| 2** |                            |     |   |                       |
|     | Are all the exterior       |     |   |                       |
|     | stairs, rails and porches  |     |   |                       |
|     | sound and free from        |     |   |                       |
|     | hazards?                   |     |   |                       |
+-----+----------------------------+-----+---+-----------------------+
| *   | **CONDITION OF ROOF AND    |     |   |                       |
| *6. | GUTTERS**                  |     |   |                       |
| 3** |                            |     |   |                       |
|     | Are the roof, gutters and  |     |   |                       |
|     | downspouts sound and free  |     |   |                       |
|     | from hazards?              |     |   |                       |
+-----+----------------------------+-----+---+-----------------------+
| *   | **CONDITION OF EXTERIOR    |     |   |                       |
| *6. | SURFACES**                 |     |   |                       |
| 4** |                            |     |   |                       |
|     | Are exterior surfaces      |     |   |                       |
|     | sound and free from        |     |   |                       |
|     | hazards?                   |     |   |                       |
+-----+----------------------------+-----+---+-----------------------+
| *   | **CONDITION OF CHIMNEY**   |     |   |                       |
| *6. |                            |     |   |                       |
| 5** | Is the chimney sound and   |     |   |                       |
|     | free from hazards?         |     |   |                       |
+-----+----------------------------+-----+---+-----------------------+
| *   | **LEAD PAINT: EXTERIOR     |     |   |                       |
| *6. | SURFACES**                 |     |   |                       |
| 6** |                            |     |   |                       |
|     | 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?                   |     |   |                       |
+-----+----------------------------+-----+---+-----------------------+
| *   | **MOBILE HOMES: TIE        |     |   |                       |
| *6. | DOWNS**                    |     |   |                       |
| 7** |                            |     |   |                       |
|     | If the unit is a mobile    |     |   |                       |
|     | home, it is properly       |     |   |                       |
|     | placed and tied down? If   |     |   |                       |
|     | not a mobile home, check   |     |   |                       |
|     | \"Not Applicable.\"        |     |   |                       |
+-----+----------------------------+-----+---+-----------------------+
| *   | **MOBILE HOMES: SMOKE      |     |   |                       |
| *6. | DETECTORS**                |     |   |                       |
| 8** |                            |     |   |                       |
|     | 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.\"              |     |   |                       |
+-----+----------------------------+-----+---+-----------------------+
| *   | **CAULKING**               |     |   |                       |
| *6. |                            |     |   |                       |
| 9** | 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, |     |   |                       |
|     | which may allow unwanted   |     |   |                       |
|     | air flow appropriately     |     |   |                       |
|     | caulked.                   |     |   |                       |
+-----+----------------------------+-----+---+-----------------------+
| **  | **OTHER**                  |     |   |                       |
| 6.1 |                            |     |   |                       |
| 0** |                            |     |   |                       |
+-----+----------------------------+-----+---+-----------------------+
| **  | **OTHER**                  |     |   |                       |
| 6.1 |                            |     |   |                       |
| 1** |                            |     |   |                       |
+-----+----------------------------+-----+---+-----------------------+

Notes: (Give Item #)

+-----+---------------------------+----+---+--------------------------+
| *   |                           | *  |   |                          |
| *7. |                           | *F |   |                          |
| HE  |                           | or |   |                          |
| ATI |                           | ea |   |                          |
| NG, |                           | ch |   |                          |
| PL  |                           | it |   |                          |
| UMB |                           | em |   |                          |
| ING |                           | n  |   |                          |
| AND |                           | um |   |                          |
| INS |                           | be |   |                          |
| ULA |                           | re |   |                          |
| TIO |                           | d, |   |                          |
| N** |                           | c  |   |                          |
|     |                           | he |   |                          |
|     |                           | ck |   |                          |
|     |                           | o  |   |                          |
|     |                           | ne |   |                          |
|     |                           | b  |   |                          |
|     |                           | ox |   |                          |
|     |                           | o  |   |                          |
|     |                           | nl |   |                          |
|     |                           | y. |   |                          |
|     |                           | ** |   |                          |
+=====+===========================+====+===+==========================+
|     |                           | DE |   |                          |
|     |                           | CI |   |                          |
|     |                           | SI |   |                          |
|     |                           | ON |   |                          |
+-----+---------------------------+----+---+--------------------------+
| I   | Description               | Ye | N | Repairs Required         |
| tem |                           | s, | o |                          |
| \#  |                           | PA | , |                          |
|     |                           | SS | F |                          |
|     |                           |    | A |                          |
|     |                           |    | I |                          |
|     |                           |    | L |                          |
+-----+---------------------------+----+---+--------------------------+
| *   | **ADEQUACY OF HEATING     |    |   |                          |
| *7. | EQUIPMENT**               |    |   |                          |
| 1** |                           |    |   |                          |
|     | 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?          |    |   |                          |
+-----+---------------------------+----+---+--------------------------+
| *   | **SAFETY OF HEATING       |    |   |                          |
| *7. | EQUIPMENT**               |    |   |                          |
| 2** |                           |    |   |                          |
|     | Is the unit free from     |    |   |                          |
|     | unvented fuel burning     |    |   |                          |
|     | space heaters, or any     |    |   |                          |
|     | other types of unsafe     |    |   |                          |
|     | heating conditions?       |    |   |                          |
+-----+---------------------------+----+---+--------------------------+
| *   | **VENTILATION AND         |    |   |                          |
| *7. | ADEQUACY OF COOLING**     |    |   |                          |
| 3** |                           |    |   |                          |
|     | Does this unit have       |    |   |                          |
|     | adequate ventilation and  |    |   |                          |
|     | cooling by means of       |    |   |                          |
|     | operable windows or a     |    |   |                          |
|     | working cooling system?   |    |   |                          |
+-----+---------------------------+----+---+--------------------------+
| *   | **HOT WATER HEATER**      |    |   |                          |
| *7. |                           |    |   |                          |
| 4** | Is hot water heater       |    |   |                          |
|     | located, equipped, and    |    |   |                          |
|     | installed in a safe       |    |   |                          |
|     | manner?                   |    |   |                          |
+-----+---------------------------+----+---+--------------------------+
| *   | **WATER SUPPLY**          |    |   |                          |
| *7. |                           |    |   |                          |
| 5** | Is the unit served by an  |    |   |                          |
|     | approvable public or      |    |   |                          |
|     | private sanitary water    |    |   |                          |
|     | supply?                   |    |   |                          |
+-----+---------------------------+----+---+--------------------------+
| *   | **PLUMBING**              |    |   |                          |
| *7. |                           |    |   |                          |
| 6** | Is plumbing free from     |    |   |                          |
|     | major leaks or corrosion  |    |   |                          |
|     | that causes serious and   |    |   |                          |
|     | persistent levels of rust |    |   |                          |
|     | or contamination of the   |    |   |                          |
|     | drinking water?           |    |   |                          |
+-----+---------------------------+----+---+--------------------------+
| *   | **SEWER CONNECTION**      |    |   |                          |
| *7. |                           |    |   |                          |
| 7** | Is plumbing connected to  |    |   |                          |
|     | an approvable public or   |    |   |                          |
|     | private disposal system,  |    |   |                          |
|     | and is it free from sewer |    |   |                          |
|     | back up?                  |    |   |                          |
+-----+---------------------------+----+---+--------------------------+
| *   | **INSULATION**            |    |   |                          |
| *7. |                           |    |   |                          |
| 8** | Are the attic and walls   |    |   |                          |
|     | appropriately insulated   |    |   |                          |
|     | for regional conditions?  |    |   |                          |
+-----+---------------------------+----+---+--------------------------+
| *   | **OTHER**                 |    |   |                          |
| *7. |                           |    |   |                          |
| 9** |                           |    |   |                          |
+-----+---------------------------+----+---+--------------------------+
| **  | **OTHER**                 |    |   |                          |
| 7.1 |                           |    |   |                          |
| 0** |                           |    |   |                          |
+-----+---------------------------+----+---+--------------------------+

Notes: (Give Item #)

+-----+---------------------------+----+---+--------------------------+
| *   |                           | *  |   |                          |
| *8. |                           | *F |   |                          |
| G   |                           | or |   |                          |
| ENE |                           | ea |   |                          |
| RAL |                           | ch |   |                          |
| HEA |                           | it |   |                          |
| LTH |                           | em |   |                          |
| AND |                           | n  |   |                          |
| SA  |                           | um |   |                          |
| FET |                           | be |   |                          |
| Y** |                           | re |   |                          |
|     |                           | d, |   |                          |
|     |                           | c  |   |                          |
|     |                           | he |   |                          |
|     |                           | ck |   |                          |
|     |                           | o  |   |                          |
|     |                           | ne |   |                          |
|     |                           | b  |   |                          |
|     |                           | ox |   |                          |
|     |                           | o  |   |                          |
|     |                           | nl |   |                          |
|     |                           | y. |   |                          |
|     |                           | ** |   |                          |
+=====+===========================+====+===+==========================+
|     |                           | DE |   |                          |
|     |                           | CI |   |                          |
|     |                           | SI |   |                          |
|     |                           | ON |   |                          |
+-----+---------------------------+----+---+--------------------------+
| I   | Description               | Ye | N | Repairs Required         |
| tem |                           | s, | o |                          |
| \#  |                           | PA | , |                          |
|     |                           | SS | F |                          |
|     |                           |    | A |                          |
|     |                           |    | I |                          |
|     |                           |    | L |                          |
+-----+---------------------------+----+---+--------------------------+
| *   | **ACCESS TO UNIT**        |    |   |                          |
| *8. |                           |    |   |                          |
| 1** | Can the unit be entered   |    |   |                          |
|     | without having to go      |    |   |                          |
|     | through another unit?     |    |   |                          |
+-----+---------------------------+----+---+--------------------------+
| *   | **EXITS**                 |    |   |                          |
| *8. |                           |    |   |                          |
| 2** | Is there an acceptable    |    |   |                          |
|     | fire exit from this       |    |   |                          |
|     | building that is not      |    |   |                          |
|     | blocked?                  |    |   |                          |
+-----+---------------------------+----+---+--------------------------+
| *   | **EVIDENCE OF             |    |   |                          |
| *8. | INFESTATION**             |    |   |                          |
| 3** |                           |    |   |                          |
|     | Is the unit free from     |    |   |                          |
|     | rats or severe            |    |   |                          |
|     | infestation by mice or    |    |   |                          |
|     | vermin?                   |    |   |                          |
+-----+---------------------------+----+---+--------------------------+
| *   | **GARBAGE AND DEBRIS**    |    |   |                          |
| *8. |                           |    |   |                          |
| 4** | Is the unit free from     |    |   |                          |
|     | heavy accumulation of     |    |   |                          |
|     | garbage or debris inside  |    |   |                          |
|     | and outside?              |    |   |                          |
+-----+---------------------------+----+---+--------------------------+
| *   | **REFUSE DISPOSAL**       |    |   |                          |
| *8. |                           |    |   |                          |
| 5** | Are there adequate        |    |   |                          |
|     | covered facilities for    |    |   |                          |
|     | temporary storage and     |    |   |                          |
|     | disposal of food wastes,  |    |   |                          |
|     | and are they approved by  |    |   |                          |
|     | a local agency?           |    |   |                          |
+-----+---------------------------+----+---+--------------------------+
| *   | **INTERIOR STAIRS AND     |    |   |                          |
| *8. | COMMON HALLS**            |    |   |                          |
| 6** |                           |    |   |                          |
|     | 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          |    |   |                          |
| *8. | HAZARDS**                 |    |   |                          |
| 7** |                           |    |   |                          |
|     | Is the interior of the    |    |   |                          |
|     | unit free from any other  |    |   |                          |
|     | hazards not specifically  |    |   |                          |
|     | identified previously?    |    |   |                          |
+-----+---------------------------+----+---+--------------------------+
| *   | **ELEVATORS**             |    |   |                          |
| *8. |                           |    |   |                          |
| 8** | 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**  |    |   |                          |
| *8. |                           |    |   |                          |
| 9** | 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   |    |   |                          |
| 8.1 | CONDITIONS**              |    |   |                          |
| 0** |                           |    |   |                          |
|     | Are the site and          |    |   |                          |
|     | immediate neighborhood    |    |   |                          |
|     | free from conditions,     |    |   |                          |
|     | which would seriously and |    |   |                          |
|     | continuously endanger the |    |   |                          |
|     | health or safety of the   |    |   |                          |
|     | residents?                |    |   |                          |
+-----+---------------------------+----+---+--------------------------+
| **  | **LEAD PAINT: OWNER       |    |   |                          |
| 8.1 | CERTIFICATION**           |    |   |                          |
| 1** |                           |    |   |                          |
|     | 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 the owner was not      |    |   |                          |
|     | required to treat         |    |   |                          |
|     | surfaces, check \"Not     |    |   |                          |
|     | Applicable.\"             |    |   |                          |
+-----+---------------------------+----+---+--------------------------+
| **  | **OTHER**                 |    |   |                          |
| 8.1 |                           |    |   |                          |
| 2** |                           |    |   |                          |
+-----+---------------------------+----+---+--------------------------+
| **  | **OTHER**                 |    |   |                          |
| 8.1 |                           |    |   |                          |
| 3** |                           |    |   |                          |
+-----+---------------------------+----+---+--------------------------+

Notes: (Give Item #)