Attachment 3 Inspection Checklist Example.pdf

Inspection Checklist U.S. Department of Housing OMB Approval No. 2577-0169 and Urban Development (Exp. 9/30/2012)

Housing Choice Voucher Program

Office of Public and Indian Housing

Public reporting burden for this collection of information is estimated to average 0.50 hours per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. This agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless that collection displays a valid OMB control number.

Assurances of confidentiality are not provided under this collection.

This collection of information is authorized under Section 8 of the U.S. Housing Act of l937 (42 U.S.C. 1437f). The information is used to determine if a unit meets the housing quality standards of the section 8 rental assistance program.

Privacy Act Statement. The Department of Housing and Urban Development (HUD) is authorized to collect the information required on this form by Section 8 of the U.S. Housing Act of 1937 (42 U.S.C. 1437f). Collection of the name and address of both family and the owner is mandatory. The information is used to determine if a unit meets the housing quality standards of the Section 8 rental assistance program. HUD may disclose this information to Federal, State and local agencies when relevant to civil, criminal, or regulatory investigations and prosecutions. It will not be otherwise disclosed or released outside of HUD, except as permitted or required by law. Failure to provide any of the information may result in delay or rejection of family participation.

Name of Family Tenant ID Number Date of Request (mm/dd/yyyy)

Inspector Neighborhood/Census Tract Date of Inspection (mm/dd/yyyy)

Type of Inspection Date of Last Inspection (mm/dd/yyyy) PHA

Initial

Special

Reinspection

A. General Information

Inspected Unit Year Constructed (yyyy) Housing Type (check as appropriate)

Full Address (including Street, City, County, State, Zip) Single Family Detached

Duplex or Two Family

Row House or Town House

Low Rise: 3, 4 Stories, Including Garden Apartment

High Rise; 5 or More Stories

Number of Children in Family Under 6

Manufactured Home

Congregate

Owner

Cooperative

Name of Owner or Agent Authorized to Lease Unit Inspected Phone Number

Independent Group

Residence

Single Room Occupancy

Address of Owner or Agent

Shared Housing

Other

B. Summary Decision On Unit (To be completed after form has been filled out)

Pass

Number of Bedrooms for Purposes Number of Sleeping Rooms of the FMR or Payment Standard

Fail

Inconclusive

Inspection Checklist Item

1. Living Room Yes No In - Final Approval

No.. Pass Fail Conc. Comment Date (mm/dd/yyyy)

1.1 Living Room Present

1.2 Electricity

1.3 Electrical Hazards

1.4 Security

1.5 Window Condition

1.6 Ceiling Condition

1.7 Wall Condition

1.8 Floor Condition

Previous editions are obsolete Page 1 of 7 form HUD-52580 (3/2001) ref Handbook 7420.8

* Room Codes: 1 = Bedroom or Any Other Room Used for Sleeping (regardless of type of room); 2 = Dining Room or Dining Area;

3 = Second Living Room, Family Room, Den, Playroom, TV Room; 4 = Entrance Halls, Corridors, Halls, Staircases; 5 = Additional Bathroom; 6 = Other

Item 1. Living Room (Continued) Yes No In- Final Approval

No. Pass Fail Conc. Comment Date (mm/dd/yyyy)

1.9 Lead-Based Paint

Not Applicable

Are all painted surfaces free of deteriorated paint?

If not, do deteriorated surfaces exceed two square feet per room and/or is more than

10% of a component?

2. Kitchen

2.1 Kitchen Area Present

2.2 Electricity

2.3 Electrical Hazards

2.4 Security

2.5 Window Condition

2.6 Ceiling Condition

2.7 Wall Condition

2.8 Floor Condition

2.9 Lead-Based Paint

2.10 Stove or Range with Oven

2.11 Refrigerator

2.12 Sink

2.13 Space for Storage, Preparation, and Serving

of Food

3. Bathroom

3.1 Bathroom Present

3.2 Electricity

3.3 Electrical Hazards

3.4 Security

3.5 Window Condition

3.6 Ceiling Condition

3.7 Wall Condition

3.8 Floor Condition

3.9 Lead-Based Paint

Previous editions are obsolete

Page 2 of 7 form HUD-52580 (3/2001)

3.10 Flush Toilet in Enclosed Room in Unit

3.11 Fixed Wash Basin or Lavatory in Unit

3.12 Tub or Shower in Unit

3.13 Ventilation

Item 4. Other Rooms Used For Living and Halls No.

Yes No In- Final Approval

Pass Fail Conc. Comment Date (mm/dd/yyyy)

4.1 Room Code* and (Circle One) (Circle One)

Room Location

Right/Center/Left Front/Center/Rear ____Floor Level

4.2 Electricity/Illumination

4.3 Electrical Hazards

4.4 Security

4.5 Window Condition

4.6 Ceiling Condition

4.7 Wall Condition

4.8 Floor Condition

4.9 Lead-Based Paint Not Applicable

4.10 Smoke Detectors

Room Location Right/Center/Left Front/Center/Rear ____Floor Level

4.9 Lead-Based Paint

(Circle One) (Circle One)

4.1 Room Code* and

Previous editions are obsolete Page 3 of 7 form HUD-52580 (3/2001) mjennin9 Highlight

No In- Final Approval No. Fail Conc. Comment Date (mm/dd/yyyy)

Room Location Right/Center/Left Front/Center/Rear ____Floor Level

4.7 Wall Condition

4.8 Floor Condition

4.1 Room Code* and

(Circle One) (Circle One)

5. All Secondary Rooms (Rooms not used for living)

5.1 None Go to Part 6

5.2 Security

5.3 Electrical Hazards

5.4 Other Potentially Hazardous

Features in these Rooms

Previous editions are obsolete Page 4 of 7 form HUD-52580 (3/2001)

Item 4. Other Rooms Used For Living and Halls Yes Pass

Item 6. Building Exterior Yes No In - Final Approval No. Pass Fail Conc. Comment Date (mm/dd/yyyy)

6.1 Condition of Foundation

6.2 Condition of Stairs, Rails, and Porches

6.3 Condition of Roof/Gutters

6.4 Condition of Exterior Surfaces

6.5 Condition of Chimney

6.6 Lead Paint: Exterior Surfaces Not Applicable

If not, do deteriorated surfaces exceed 20 square feet of total exterior surface area?

6.7 Manufactured Home: Tie Downs

7. Heating and Plumbing

7.1 Adequacy of Heating Equipment

7.2 Safety of Heating Equipment

7.3 Ventilation/Cooling

7.4 Water Heater

7.5 Approvable Water Supply

7.6 Plumbing

7.7 Sewer Connection

8. General Health and Safety

8.1 Access to Unit

8.2 Fire Exits

8.3 Evidence of Infestation

8.4 Garbage and Debris

8.5 Refuse Disposal

8.6 Interior Stairs and Commom Halls

8.7 Other Interior Hazards

8.8 Elevators

8.9 Interior Air Quality

8.10 Site and Neighborhood Conditions

8.11

Lead-Based Paint: Owner's Certification

If the owner is required to correct any lead-based paint hazards at the property including deteriorated paint or other hazards identified by a visual assessor, a certified lead-based paint risk assessor, or certified lead-based paint inspector, the PHA must obtain certification that the work has been done in accordance with all applicable requirements of 24 CFR Part 35. The Lead -Based Paint Owner Certification must be received by the PHA before the execution of the HAP contract or within the time period stated by the PHA in the owner HQS violation notice.

Receipt of the completed and signed Lead-Based Paint Owner Certification signifies that all HQS lead-based paint requirements have been met and no re-inspection by the HQS inspector is required.

Previous editions are obsolete Page 5 of 7 form HUD-52580 (3/2001) ref Handbook 7420.8 mjennin9 Highlight mjennin9 Highlight

C. Special Amenities (Optional) This Section is for optional use of the HA. It is designed to collect additional information about other positive features of the unit that may be present.

Although the features listed below are not included in the Housing Quality Standards, the tenant and HA may wish to take them into consideration in decisions about renting the unit and the reasonableness of the rent.

Check/list any positive features found in relation to the unit.

1. Living Room

High quality floors or wall coverings Working fireplace or stove Balcony, patio, deck, porch Special windows or doors Exceptional size relative to needs of family Other: (Specify)

2. Kitchen

Dishwasher Separate freezer Garbage disposal Eating counter/breakfast nook Pantry or abundant shelving or cabinets Double oven/self cleaning oven, microwave Double sink High quality cabinets Abundant counter-top space Modern appliance(s)

3. Other Rooms Used for Living

High quality floors or wall coverings Working fireplace or stove Balcony, patio, deck, porch Special windows or doors

4. Bath

Special feature shower head Built-in heat lamp Large mirrors Glass door on shower/tub Separate dressing room Double sink or special lavatory

5. Overall Characteristics

Storm windows and doors Other forms of weatherization (e.g., insulation, weather stripping) Screen doors or windows Good upkeep of grounds (i.e., site cleanliness, landscaping, condition of lawn) Garage or parking facilities Driveway Large yard Good maintenance of building exterior

6. Disabled Accessibility

Unit is accessible to a particular disability. Yes No Disability ___________________________

D. Questions to ask the Tenant (Optional)

1. Does the owner make repairs when asked? Yes No

2. How many people live there? ___________

3. How much money do you pay to the owner/agent for rent? $ _________________

4. Do you pay for anything else? (specify) ___________________________________________________________________________

5. Who owns the range and refrigerator? (insert O = Owner or T = Tenant) Range ______ Refrigerator _____ Microwave ______

6. Is there anything else you want to tell us? (specify) Yes No

Previous editions are obsolete Page 6 of 7 form HUD-52580 (3/2001)

E. Inspection Summary/Comments (Optional) Provide a summary description of each item which resulted in a rating of "Fail" or "Pass with Comments."

Tenant ID Number Inspector Date of Inspection (mm/dd/yyyy) Address of Inspected Unit

Type of Inspection Initial Special Reinspection

Item Number Reason for "Fail" or "Pass with Comments" Rating

Continued on additional page Yes No

Previous editions are obsolete Page 7 of 7 form HUD-52580 (3/2001)