Attachment 3 PAPER INSPECTION FORM 031408.xlsx

XLSX spreadsheet 81 KB Posted Mar 24, 2011

Attached to: Special Notice Housing Inspection Services Contract
Solicitation number: HSFEHQ-11-R-0041
Issued by: Federal Emergency Management Agency Recovery Section

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File	Type	Posted
Question and Answers 4.15.2011.docx	DOCX document	Apr 15, 2011
Attachment 12 Deliverables.docx	DOCX document	Mar 24, 2011
Attachment 14 119-7-1 Personal Property Manual	—	Mar 24, 2011
Attachment 8 Shelter Inspection.docx	DOCX document	Mar 24, 2011
Attachment 4 DHS Handbook.docx	DOCX document	Mar 24, 2011
Attachment 9a 009-0-3 Declaration and Release Form English former 90-69B.pdf	PDF	Mar 24, 2011
Attachment 13 Matrix.docx	DOCX document	Mar 24, 2011
Attachment 10 Standards for Correction - Jan 2010.docx	DOCX document	Mar 24, 2011
Attachment 6 PRIVACY AWARENESS TRAINING.docx	DOCX document	Mar 24, 2011
Attachment 5 a Customer Satisfaction Survey .doc	DOC document	Mar 24, 2011
Attachment 7 IHP Inspection Guidelines.docx	DOCX document	Mar 24, 2011
Attachment 9b 009-0-4 Declaration and Release form Spanish former 90-69C.pdf	PDF	Mar 24, 2011
Attachment 5 B Customer Satisfaction Survey Spanish.docm	DOCM document	Mar 24, 2011
Attachment 12 Deliverables 3.21.11.docx	DOCX document	Mar 22, 2011
PWS as of 3.21.11.docx	DOCX document	Mar 22, 2011
Attachment 12 Deliverables 3.21.11.docx	DOCX document	Mar 21, 2011
PWS as of 3.21.11.docx	DOCX document	Mar 21, 2011

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Sheet3 Registration Information Reg ID # _______________ Page

Name And E-mail _______________________________________________________________________

Employment

Self Employed

YES

Income

Address of Damaged Dwelling

Street

City

State

Zip Code

Mailing Address

Check if same as above

Street

City

State

Zip Code

Phone Numbers

Primary:

Residence Primary

Alternate

Occupancy Type

Not Primary Residence

Owner/ Rent Free

Renter

Occupancy Verified

_______

Driver's License

_______

Employer's Statement

_______

Utility Bill

_______ Not Verified _______ Merchants Statement _______ Voter Registration

	Landlord	Name and Phone Number
Ownership Verified By
_______	Affidavits		_______	Mortgage Payment Book
				Company	________________________________________________
_______	Title number			Loan Number		_____________________________________________
				Phone Number

_______

Not Verified

_______

Official's Record

_______

Tax Bill

_______

Structural Insurance

Policy Number

_________________________________________________________________

Insurance Company

______________________________________________________________

Insurance Type

_________________________________________________________________

Agent

Phone

9069 Signatures:

Registration signed

_____

YES

_____

US Citizen/ Non-Citizen national

Declaration Signed

_____

YES

_____

Qualified Alien

_____

Parent/Guardian of minor who is a US Citizen

________

# Require Clothing

_____

Bedrooms Occupied

_____

Household Comp

Clothing Cause of Damage

Clothing Loss Verification:

Viewed

Verbal

Not Verified

Dwelling Information

Last Name

First Name

Relationship

Age

Dependent

High Water Floor

_____

Crawlspace

_____

Basement

_____

1st Floor

_____

2nd Floor

_____

3rd Floor

Attic

Foundation

_____

Basement

_____

Walk out Basement

_____

Crawlspace

_____

Slab

Other

Other =

Dwelling

_____

1 Story

_____

2 Story

_____

3 or More Stories

_____

Mobile Home/ Travel trailer

Split Level

Other

Other =

								Reg ID # ___________Page
Personal Property
Damage Level N/A = Not Affected X = Repair Z = Replace
Loss Verifications: V = Viewed During Inspection VBL = Verbal Damage Support Claim
	NV = Not Verified, Losses Not Supported by Damages
Appliance/ Mechanical Device		n/a	X	Z	Cause	QTY	V	VBL	NV	Floor	Room
ADA accessible toilet seat
ADA accessible washer
ADA accessible refrigerator
Appliance service call
Air Conditioner
Carbon Monoxide (CO) Detector
Chainsaw
Dehumidifier
Dryer
Electric Fan
Everyday Dining Table/ Chairs
FEMA Mobile Home - TT
Freezer
Generator
Humidifier
Infant Car Seat- modified
Infant Crib
Infant High Chair
Infant Play Pen
Infant Stroller
Microwave
No Appliance Damage
Portable Space Heater
Radio
Range
Refrigerator
Telephone
Television
Toys
Twin Bed
Vacuum
Washer

Room Furnishings
Damage Level: N/A = Not Affected X = Repair Z = Replace
Loss Verifications: V = Viewed During Inspection VBL = Verbal Damage Support Claim
		NV = Not Verified, Losses Not Supported by Damages
Room Type	QTY		FLOOR(S)	N/A	X	Y	Z	COD	V	VBL	NV
Basement
Bathroom
Bedroom
Boarder occupied
Dinning Room
Exterior
Garage
Hallway
Kitchen
Living room
No Furnish/Damage
Office
Utility

Reg ID # ___________Page

Unmet Needs

Transportation

Level Of Damage: n/v = Not Available n/a = Not Affected

Year

Make

Model

COD

n/v

n/a

Comprehensive

Liability

Registered

__ Yes ___ No

Vehicle Type of Damage: Broken Windshield____ Major Body Damage_____Other_____

Signal/Brake/Headlights_____Water Over Engine_____

Loss Verification

Unmet Needs

▼

Essential Tools

COD

▼

Miscellaneous purchase

COD

Dental

Yes

Computer

Chainsaw post incident

Medical/ Medical PP

Yes

Occup tools

dehumidifier post incident

Funeral

Yes

Books/ uniforms

Generator 5.5KW

Moving & Storage

Yes

Uniforms

Humidifier

Essential Tools

Yes

Other

Misc. Purchase

Yes

Viewed

VBL

Not Verified

Receipts and date

Post Inspection

Utilities out

Yes

Inaccessible

Yes

Habitability repairs req.

Yes

Have you moved or are you going to move while repairs are made

Yes

Home Unsafe Reasons _____Accessibility Item

_____

Access Blocked (not R&B)

_____

Boat

_____

Debris Hazard

_____

Destroyed

_____

Electrical

_____

Floors/Walls/Ceilings

_____

Forced to Relocate

_____

Foundation/Masonry

_____

Heating

_____

Imminent Danger

_____

Plumbing

_____

Roof

_____

Sanitation/Safety

_____

Single/Multi Family R&B

_____

Tagged Structure

_____

Utilities

_____

Windows/Doors

Areas of Deferred Maintenance

_____

Access/Debris

_____

Boat items

_____

Electrical

_____

Floors/Walls/Ceilings

_____

Heating

_____

Foundation/Masonry

_____

General

_____

Mobile Home

_____

Plumbing

_____

Roads/Bridges

_____

Sanitation

_____

Utility

_____

Windows/Doors

Type of Residence
_____	Apartment	_____	Boat	_____	Condo	_____	House-single/Duplex		__	Mobile Home
_____	Townhouse	_____	Travel Trailer		_____	Other		Other=

Size of Residence		Conflict of Interest	__	Yes	__	No
	SQFT
Required Comments:

REAL PROPERY
LINE ITEMS	UOM	QTY	COD	FLOOR	ROOM
ACCESS/DEBRI
Clean & Sanitize	SF
Debris, Remove	CY
Fence, Chain link, Replace	LF
Fence, Repair	LF
Lump Sum	EA
Pump Out	EA
Retaining Wall, Replace	SF
Service Call	EA
Tree(s), Remove	EA
Washout	CY
BOAT ITEMS
Anchor, Replace	EA
Batteries, Replace	EA
Bilge Pump, Replace	EA
Cabinet, Remove & Reinstall	EA
Cabinet, Replace	EA
Cleats	EA
Deck, Repair	SF
Docking Rope	LF
Door, Replace	EA
Dry Dock	LF
Fender, Replace	EA
Gate Stanchion	EA
Generator, Repair	EA
Generator, Replace	EA
Hatches, Replace	EA
Hull, Paint	LF
Hull, Repair	SF
Inverter, Replace	EA
Keel, Repair	LF
Life Line	LF
Life Preserver	EA
Lump Sum	EA
Mooring	EA
Porthole, Replace	EA
Railing	LF
Service Call	EA
Solar Panel, Replace	EA
Stanchion	EA
Toe Rail	LF
Toilet, Replace	EA
Water Pump, Replace	EA
Water Tank, Repair	EA
Water Tank, Replace	EA
Wind Generator, Replace	EA
ELECTRICAL
Aux Panel, Replace	EA
Cir Breaker, 1 Pole, Replace	EA
Cir Breaker, 2 Pole, Replace	EA
Cir Breaker, GFI, Replace	EA
Fuses, Replace	EA
Generator, Replace	EA
Light Fix w/ Fan, Replace	EA
Light Fixtures, Replace	EA
Lump Sum	EA
Main Breakers, 100 Amp, Replace	EA
Main Breakers, 200 Amp, Replace	EA
Main Panel, 100 Amp, Replace	EA
Main Panel, 200 Amp, Replace	EA
Main Panel, Clean & Repair	EA
Mast, 10 LF, Replace	EA
Meter Base, Replace	EA
Outlet, 220 Volt, Replace	EA
Outlet, GFI, Replace	EA
Outlets or Switches, Replace	EA
Power Pole, Replace	EA
Power Pole, Reset	EA
Service Call	EA
Service Entrance, Replace	EA
Wiring, Replace	LF
FLOORS/WALLS/CEILINGS
Carpet, Re-stretch	SF
Ceiling Joist, Replace	SF
Floor Covering, Replace	SF
Floor Joist, Replace	SF
Floor, Hardwood, Replace	SF
Floor, Overlay	SF
Floor, Sand & Refinish	SF
Floor, Sub, Replace	SF
Insulation, Replace	SF
Lump Sum	EA
Paint	SF
Service Call	EA
Sheetrock, Finish	SF
Sheetrock, Replace	SF
Siding, Replace	SF
Smoke Detector, Replace	EA
Stucco, Replace	SF
Support Column, Wood, Replace	EA
Tile, Wall, Replace	SF
Wall, Exterior, Replace	SF
Wall, Interior, Replace	SF
FOUNDATION/MASONRY
Chimney Cap, Replace	EA
Chimney Clean & Inspect	EA
Chimney, Remove	LF
Chimney, Replace	LF
Concrete Foundation. Wall, Replace	SF
Concrete Slab, Replace	SF
Concrete, Pressure Grout	LF
Firebrick, Replace	SF
Foundation Knee Wall, Replace	SF
Foundation. Footing, Replace	LF
Jack & Relevel	SF
Jack & Shore	SF
Jack House, Reset on Foundation.	SF
Lally Column, Replace	EA
Lump Sum	EA
Masonry Access Steps, Replace	EA
Masonry Fireplace, Remove	EA
Masonry Fireplace, Replace	EA
Masonry Veneer, Replace	SF
Pier, Replace	EA
Service Call	EA
Stone/Brick Ext. Wall, Replace	SF
Tuck Point	LF
GENERAL
Access Porch, Fabricate	EA
Cabinet, Base, Replace	LF
Cabinet, Reinstall	LF
Cabinet, Vanity, Replace	LF
Cabinet, Wall, Replace	LF
Down Spouts, Replace	LF
Flashing, Replace	LF
Handicap Grab Bars, Replace	EA
Handicap Ramp, Replace	EA
Lump Sum	EA
Rain Gutters, Replace	LF
Residence, Rebuild	EA
Roof Vent, Replace	EA
Roof, Concrete, Reseal	SF
Roof, Covering Only, Replace	SF
Roof, Framing & Up, Replace	SF
Roof, Metal, Renail & Seal	SF
Roof, Metal, Replace	SF
Roof, Sheathing & Up, Replace	SF
Roof, Tile, Replace	SF
Roof, Tile, Reset	SF
Room, Detached, Construct	SF
Service Call	EA
Soffit & Facia, Replace	LF
Stairs, Handrail, Replace	LF
Stairs, Treads, Replace	EA
HEATING
Black Pipe, Replace	LF
Buried Gas Line, Replace	LF
Central Air Cond., Repair	EA
Central Air Cond., Replace	EA
Ductwork, Clean & Sanitize	LF
Ductwork, Replace	LF
Fireplace, Gas Heat Circulating (ô42x36ö), Replace	EA
Furnace, Clean & Repair	EA
Furnace, Clean & Test	EA
Furnace, Floor, Replace	EA
Furnace, Replace	EA
Gas Flue, Replace	LF
Heater, Wall, Clean & Test	EA
Heater, Baseboard, Replace	LF
Heater, Portable, Provide	EA
Lump Sum	EA
Oil Tank, Replace	EA
Oil Tank, Reset	EA
Oil Tank, Stop, Replace	EA
Propane Regulators, Replace	EA
Propane Tank, Replace	EA
Propane Tank, Reset	EA
Service Call	EA
Thermostat, Replace	EA
Wall Heater, Electric, Replace	EA
Wall Heater, Gas, Replace	EA
Wood St Flue, 3 Wall, Replace	LF
Wood Stove, Replace	EA
MOBILE HOME
Anchors, Replace	EA
Bottom Board/Ins., Replace	SF
Double Wide, Block & Level	EA
Double Wide, Relevel	EA
Lump Sum	EA
Mobile Home, Replace	EA
TT Permanent Foundation	EA
TT Non-Permanent Foundation	EA
Service Call	EA
Single Wide, Block & Level	EA
Single Wide, Relevel	EA
Skirting, Replace	SF
Travel Trailer, Replace	EA
Utilities, Reconnect	EA
MULTI-FAMILY ROAD
MF Abutment - in Water	SF
MF Abutment - on Shore	SF
MF Beam, Steel, Replace	LF
MF Beam, Timber, Replace	LF
MF Culvert 12-30", Replace	LF
MF Culvert 36"+, Replace	LF
MF Decking, Replace	SF
MF Footbridge, Replace	LF
MF Low-Water Bridge, Replace	LF
MF Lump Sum	EA
MF Machine Time	HOUR
MF Road Fill	CY
MF Service Call	EA
MF Wingwall, Replace	SF
Multi-Family Debris Remove	CY
PLUMBING
Drain Line, Replace	LF
Drain Lines, Rout & Flush	EA
Faucets, Replace	EA
Fixture, Remove & Cap drain	EA
Lump Sum	EA
Service Call	EA
Shower Enclosure, Replace	EA
Shower/Tub Door, Replace	EA
Sink, Bathroom, Reinstall	EA
Sink, Bathroom, Replace	EA
Sink, Kitchen, Reinstall	EA
Sink, Kitchen, Replace	EA
Toilet & Tank, Reinstall	EA
Toilet & Tank, Replace	EA
Tub, Reinstall	EA
Tub, Replace	EA
Water Heater, Repair	EA
Water Heater, Replace	EA
Water Line, Buried, Replace	LF
Water Line, Replace	LF
SF ROAD/BRIDGE
SF Abutment - in Water	SF
SF Abutment - on Shore	SF
SF Beam, Steel, Replace	LF
SF Beam, Timber, Replace	LF
SF Culvert 12-30", Replace	LF
SF Culvert 36"+, Replace	LF
SF Decking, Replace	SF
SF Footbridge, Replace	LF
SF Low-Water Bridge, Replace	LF
SF Lump Sum	EA
SF Machine Time	HOUR
SF Road Fill	CY
SF Service Call	EA
SF Wingwall, Replace	SF
SPEED ESTIMATING
Electrical, Complete	SF
Heating, Complete	SF
Missed 2nd appt w/inspector	EA
UTILITIES
Cistern, Replace	EA
Cistern, Reseal	EA
Lump Sum	EA
Outhouse, Replace	EA
Outside Shower, Replace	EA
Septic Drain Field, Replace	EA
Septic Tank Lid, Replace	EA
Septic Tank, Pump Out	EA
Septic Tank, Replace	EA
Service Call	EA
Sewer Line, Auger	EA
Sewer Line, Replace	LF
Sump Pump, Replace	EA
Water Supply, Decontaminate	EA
Water Tank Lid, Replace	EA
Well Pressure Tank, Replace	EA
Well Pump (500+ gal) Storage	EA
Well Pump Electric Line, Replace	LF
Well Pump House, Replace	EA
Well Sub Pump, Replace	EA
Well Surface Pump, Repair	EA
Well Surface Pump, Replace	EA
Well, Replace	LF
WINDOWS/DOORS
Door, Exterior, Replace	EA
Door, Interior, Replace	EA
Door, Sliding Glass, Replace	EA
Door, Storm, Replace	EA
Door, Trim & Refit	EA
Lump Sum	EA
Screen, Replace	SF
Service Call	EA
Skylight, Replace	EA
Window Glass, Replace	SF
Window, Miami Louver, Replace	EA
Window, Replace	EA

File details come from the government source that posted it. Updated Nov 14, 2017.