1.1.4 ATTACHMENT 12 - Ready for Occupancy Status Form.pdf

FEMA FORM FF-104-FY-21-191 (formerly 009-0-129) (7/22)

DEPARTMENT OF HOMELAND SECURITY

TRANSPORTABLE TEMPORARY HOUSING UNIT

READY FOR OCCUPANCY STATUS

Federal Emergency Management Agency

FEMA RFO Checklist Contract #: Task Order #: Type of TTHU: Date of Inspection:

Inspector Name:

FEMA Monitor Name:

Address: TTHU Barcode: TTHU VIN:

Inspector Signature:

FEMA Monitor Signature:

City, State:

UFAS:

Phone Number:

Note: Descriptions in this document are for reference only. The requirements are found in the contract. Descriptions in this document do not supersede any of the requirements in the contract.

EXTERIOR INITIALS

ITEM DESCRIPTION YES NO N/A CONTRACTOR

CERTIFICATION FEMA MONITOR

PLACING/SECURING

BLOCKING

Is the TTHU blocked according to the solicitation, state or local entity requirements, and/or manufacturer specifications?

LEVEL Is the TTHU level and elevated if required?

TIE DOWNS

ANCHORING Is the TTHU anchored safely and securely?

UTILITIES

WATER Is the water piping connected and working properly?

SEWER Is the sewage system connected properly (check slope, etc.) and in working condition?

ELECTRIC Are all the electrical components working properly?

Phone Number:

Is the TTHU tied down safely and securely?

PAPERWORK BURDEN DISCLOSURE NOTICE

Public reporting burden for this form is estimated to average 20 minutes per response. The burden estimate includes the time for reviewing instructions, searching existing data sources, gathering and maintaining the needed data, and completing, reviewing, and submitting the form.

This collection of information is mandatory. You are not required to respond to this collection of information unless a valid OMB control number appears in the upper right corner of this form. Send comments regarding the accuracy of the burden estimate and any suggestions for reducing this burden to: Information Collections Management, Department of Homeland Security, Federal Emergency Management Agency, 500 C Street, SW, Washington, DC, 20472, Paperwork Reduction Project (1660-0138). Please do not send your completed survey to the above address.

PRIVACY ACT STATEMENT

AUTHORITY: The Robert T. Stafford Disaster Relief and Emergency Assistance Act as amended, 42 U.S.C. § 5174 and Title 44 C.F.R. Part 206.117.

PRINCIPAL PURPOSE(S): This information is being collected for the primary purpose of determining the ready for occupancy (RFO) status of a Transportable Temporary Housing Unit (TTHU) prior to its use as a form of direct temporary housing assistance under a Presidentially-declared disaster.

ROUTINE USE(S): The information on this form may be disclosed as generally permitted under 5 U.S.C. § 552a(b) of the Privacy Act of 1974, as amended. This includes using this information as necessary and authorized by the routine uses published in DHS/FEMA - 008 Disaster Recovery Assistance Files System of Records, 78 Fed. Reg. 25282 (Apr. 30, 2013), and upon written request, by agreement, or as required by law.

DISCLOSURE: The disclosure of information on this form is voluntary; however, failure to provide the information requested may delay or prevent the applicant from receiving the requested disaster-related temporary housing assistance.

OMB Control Number: 1660-0138 Expiration Date: 07/31/2025

YES NO

TRANSPORTABLE TEMPORARY HOUSING UNIT READY FOR OCCUPANCY STATUS

INTERIOR

KITCHEN

FLOOR Is the floor in good condition?

WALLS Are the walls in good condition?

CEILING Is the ceiling in good condition?

LIGHTING Are all lighting components functioning properly?

OUTLETS Are all outlets functioning properly?

CABINETS Are all cabinets in good condition?

SINK Is the sink functioning properly?

EXTINGUISHER Is the fire extinguisher present and in working condition?

FURNISHINGS Are all the furnishings in good condition?

BLINDS Are all blinds present and in good condition?

RANGE Is the range functioning properly?

REFRIGERATOR Is the refrigerator functioning properly?

APPLIANCES

MICROWAVE Is the microwave functioning properly?

RANGE HOOD Is the range hood functioning properly?

WATER HEATER Is the water heater functioning properly?

CLEAN AND MAKE

READY Is the TTHU clean?

FLOOR Is the floor in good condition?

WALLS Are the walls in good condition?

LIVING ROOM

ENTRY

STEP Is the entry component installed and safe to use?

PLATFORM STAIR Is the entry component installed and safe to use?

RAMP Is the entry component installed and safe to use?

DOOR/LOCKS Are the exterior locks and door functioning properly?

EXTERIOR STRUCTURE

WINDOWS Are all windows present and functional?

ROOF Is the roof in good condition?

SIDING Is the siding in good condition?

Is the Tank and Pump System installed and ready to use?

TANK AND PUMP SYSTEM (TPS)

ITEM DESCRIPTION YES NO N/A CONTRACTOR

CERTIFICATION FEMA MONITOR

FLOOR COVERING Is the floor covering in good condition?

WEATHER RADIO Is the Weather Radio functioning properly?

FLOOR COVERING Is the floor covering in good condition?

TUB/SHOWER Is the tub/shower present and functioning properly?

COMMODE Is the commode functioning properly?

CLEAN AND MAKE

READY Is the TTHU clean?

TRANSPORTABLE TEMPORARY HOUSING UNIT READY FOR OCCUPANCY STATUS

FLOOR Is the floor in good condition?

WALLS Are the walls in good condition?

CEILING Is the ceiling in good condition?

BATHROOM 2

VENT FAN Is the vent fan functioning properly?

DOOR Is the door in good condition?

LIGHTING Are all lighting components functioning properly?

OUTLETS Are all outlets functioning properly?

CABINETS Are all cabinets in good condition?

FIXTURES Are all fixtures present and functioning properly?

TUB/SHOWER Is the tub/shower in good condition and functioning properly?

COMMODE Is the commode functioning properly?

SINK Is the sink in good condition and functioning properly?

CLEAN AND MAKE

READY Is the TTHU clean?

LIGHTING Are all lighting components functioning properly?

OUTLETS Are all outlets functioning properly?

FURNISHINGS Are all furnishings in good condition?

BLINDS Are all blinds present and in good condition?

SMOKE/STROBES Is the smoke alarm functioning properly?

CLEAN AND MAKE

READY Is the TTHU clean?

FLOOR Is the floor in good condition?

WALLS Are the walls in good condition?

CEILING Is the ceiling in good condition?

LIGHTING Are all lighting components functioning properly

OUTLETS Are all outlets functioning properly?

BATHROOM 1

FIXTURES Are all fixtures present and functioning properly?

CEILING Is the ceiling in good condition?

ITEM DESCRIPTION YES NO N/A CONTRACTOR

CERTIFICATION FEMA MONITOR

FLOOR COVERING Is the floor covering in good condition?

SINK Is the sink in good condition and functioning properly?

CEILING Is the ceiling in good condition?

LIGHTING Are all lighting components functioning properly?

OUTLETS Are all outlets functioning properly?

FURNISHINGS Are all furnishings in good condition?

BLINDS Are all blinds present and in good condition?

SMOKE/STROBES Is the smoke alarm functioning properly?

CLEAN AND MAKE

READY Is the TTHU clean?

DOOR Is the door in good condition?

TRANSPORTABLE TEMPORARY HOUSING UNIT READY FOR OCCUPANCY STATUS

FLOOR Is the floor in good condition?

WALLS Are the walls in good condition?

CEILING Is the ceiling in good condition?

LIGHTING Are all lighting components functioning properly?

OUTLETS Are all outlets functioning properly?

FURNISHINGS Are all furnishings in good condition?

BLINDS Are all blinds present and in good condition?

SMOKE/STROBES Is the smoke alarm functioning properly?

BEDROOM 3

CLEAN AND MAKE

READY Is the TTHU clean?

DOOR Is the door in good condition?

FLOOR Is the floor in good condition?

WALLS Are the walls in good condition?

CEILING Is the ceiling in good condition?

LIGHTING Are all lighting components functioning properly?

OUTLETS Are all outlets functioning properly?

FURNISHINGS Are all furnishings in good condition? Are the mattresses new?

BLINDS Are all blinds present and in good condition?

SMOKE/STROBES Is the smoke alarm functioning properly?

BEDROOM 1

CLEAN AND MAKE

READY Is the TTHU clean?

DOOR Is the door in good condition?

BEDROOM 2

FLOOR Is the floor in good condition?

WALLS Are the walls in good condition?

ITEM DESCRIPTION YES NO N/A CONTRACTOR

CERTIFICATION FEMA MONITOR

FLOOR COVERING Is the floor covering in good condition?

FLOOR Is the floor in good condition?

WALLS Are the walls in good condition?

CEILING Is the ceiling in good condition?

DRYER VENT

INSTALLED Is the dryer vent functioning properly?

SMOKE/STROBES Is the smoke alarm functioning properly?

HALLWAY

CLEAN AND MAKE

READY is the TTHU clean?

HVAC Is the HVAC in good condition?

ADDITIONAL COMMENTS

TRANSPORTABLE TEMPORARY HOUSING UNIT READY FOR OCCUPANCY STATUS

ITEM DESCRIPTION YES NO N/A CONTRACTOR

CERTIFICATION FEMA MONITOR