Housing Choice Voucher Program Inspection Form Page 13
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194.
Supplemental for Other Rooms Used for Living and Halls
For each numbered item, check one box only.
4.1
Room Location
Room Code
______ right/left/center:
the room is situated to the right, left,
1 = Bedroom or Any Other Room Used for Sleeping (regardless of
or center of the unit.
type of room)
______ front/rear/center: the room is situated to the back, front
2 = Dining Room or Dining Area
or center of the unit.
3 = Second Living Room, Family Room, Den, Playroom, TV Room
______ floor level:
the floor level on which the room is
4 = Entrance Halls, Corridors, Halls, Staircases
located.
5 = Additional Bathroom (also check presence of sink trap and
clogged toilet)
6 = Other:
Decision
Item
Description
If Fail or
No.
If Fail, what repairs are necessary?
Inconclusive,
If Inconclusive, give details.
date (mm/dd/yyyy)
If Pass with comments, give details.
of final approval
4.2
Electricity/Illumination
If Room Code is a 1, are there at least two working
outlets or one working outlet and one working,
permanently installed light fixture?
If Room Code is not a 1, is there a means of illumination?
4.3
Electrical Hazards
Is the room free from electrical hazards?
4.4
Security
Are all windows and doors that are accessible from
the outside lockable?
4.5
Window Condition
If Room Code is a 1, is there at least one window?
And, regardless of Room Code, are all windows
free of s igns of severe d eterioration or m issing or
broken-out panes?
4.6
Ceiling Condition
I s the ceiling sound and free from hazardous defects?
4.7
Wall Condition
Are the walls sound and free from hazardous defects?
4.8
Floor Condition
Is the floor sound and free from hazardous defects?
4.9
Lead-Based Paint
Are all painted surfaces free of deteriorated paint?
If no, does deteriorated surfaces exceed two square
Not Applicable
feet and/or more than 10% of a component?
4.10 Smoke Detectors
Is there a working smoke detector on each level?
Do the smoke detectors meet the requirements of
NFPA 74?
In units occupied by the hearing impaired, is there an
alarm system connected to the smoke detector?
Additional Comments: (Give Item Number)(Use an additional page if necessary)
Comments continued on a separate page
Yes
No
Previous editions are obsolete
Page 13 of 19
ref Handbook 7420.8 form HUD-52580-A (9/00)
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