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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 Current Telephone of Family B. How to Fill Out This Checklist q Proceed through the inspection as follows Area Room by Room Checklist Category 1. Living Room 2. Kitchen 3. Bathroom 4. All Other Rooms Used for Living Outside Basement or Utility Room Overall 5. All Secondary Rooms Not Used for Living 6. Building Exterior 7. Heating and Plumbing 8. General Health and Safety q Each part of the checklist will be accompanied by an explanation of the item to be inspected* q 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. q 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. q 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. LIVING ROOM Item Description LIVING ROOM PRESENT Is there a living room ELECTRICITY Are there at least two working outlets or one working outlet and one working light fixture ELECTRICAL HAZARDS Is the room free from electrical hazards SECURITY Are all windows and doors that are accessible from the outside lockable WINDOW CONDITION Is there at least one window and are all windows free of signs of severe deterioration or missing or broken out panes CEILING CONDITION Is the ceiling sound and free from hazardous defects WALL CONDITION Are the walls sound and free from hazardous FLOOR CONDITION Is the floor sound and free from hazardous LEAD PAINT Are all interior surfaces either free of cracking scaling peeling chipping and loose paint or adequately treated and covered to prevent exposure of the occupants to lead based paint hazards WEATHER STRIPPING Is weather stripping present and in good condition on all windows and exterior doors OTHER Notes Give Item For each item numbered check one box only. DECISION Yes No PASS FAIL Repairs Required 2. KITCHEN KITCHEN AREA PRESENT Is there a kitchen one working permanently installed light fixture Is the kitchen free from electrical hazards STOVE OR RANGE WITH OVEN Is there a working oven and a stove or range with top burners that work REFRIGERATOR Is there a refrigerator that works and maintains a temperature low enough so that food does not spoil over a reasonable period of time SINK cold running water SPACE FOR STORAGE AND PREPARATION OF FOOD Is there space to store and prepare food 3. BATHROOM BATHROOM see description Is there a bathroom Is the bathroom free from electrical hazards FLUSH TOILET IN ENCLOSED ROOM IN UNIT private use of the tenant FIXED WASH BASIN OR LAVATORY IN basin with hot and cold running water in the unit TUB OR SHOWER IN UNIT VENTILATION Are there operable windows or a working vent system 4. OTHER ROOMS USED FOR LIVING AND HALLS ROOM CODE and ROOM LOCATION right/left front/rear floor level If Room Code 1 are there at least two working permanently installed light fixture If Room Code does not 1 is there a means of illumination 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 PASS FAIL 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 5.

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