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Health and Safety Inspection Checklist

The document is a health and safety inspection checklist for a building. It lists areas to inspect for issues like heating, electrical, plumbing, indoor air quality, structural hazards, and mold. If mold is found, the areas are noted and whether cleanup is required before weatherization work.

Uploaded by

Benson Cherian
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62 views2 pages

Health and Safety Inspection Checklist

The document is a health and safety inspection checklist for a building. It lists areas to inspect for issues like heating, electrical, plumbing, indoor air quality, structural hazards, and mold. If mold is found, the areas are noted and whether cleanup is required before weatherization work.

Uploaded by

Benson Cherian
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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Health and Safety Inspection Checklist

Agency: Date: Building ID #:


Address:
Customer: Inspector:

Appliances and Mechanical Systems Pass Fail Recommendation


Heating System
Water heater - properly vented; tank leakage
Electrical System - adequate service; grounded
properly; exposed wires/ or connections
Plumbing Facilities - water supply or drain leak; unsanitary
conditions
Appliances - gas leaks; poor electrical connections; CO
Specify Other:
Indoor Air Quality
If building fails moisture conditions, complete the Moisture Pass Fail Recommendation
Audit.
Moisture Problems - mold or mildew present
Standing Water in low areas
Suspect Asbestos that is friable and may be a hazard
Ventilation
Structural Hazards Pass Fail Recommendation
Roof Condition
Wall Condition
Foundation Condition
Floor Condition
Ceiling Condition
Interior and Exterior Stairways
Window and Door Condition
Carbon Monoxide (CO) Alarms
Smoke Alarms - one per floor in working order
Lead Paint - peeling paint that may contain lead
Other:
Based on our initial review of your building, we have identified the above potential health or safety problems. This is a
limited visual inspection. These are the existing conditions as of the date below. By signing below, you acknowledge
that you have been informed of the conditions and may have to address some of the items prior to any weatherization
work. This form is not a guarantee of weatherization service.

Customer/Tenant Signature: Date:

Owner Signature: Date:


(If different from customer)

Agency Representative: Date:

Revised June 2012


Health and Safety Inspection Checklist

Moisture Areas: Existing conditions (check all that apply)


Damp atmosphere in house
Client complaint of allergy-like symptoms
Visible mold growth (if “Yes”, go to the Checklist below)
Evidence of water penetrating the home (stains, moist areas)
Evidence of conditions that might allow water in the home (poor grading, bad flashing,
bad/missing gutters)
Actual construction defect or deterioration that allows water into the home (roof, decks, windows,
concrete slabs, lack of vapor barrier)
Plumbing defects (leaking drains, pipes or toilets, missing caulk on sinks or tubs)
HVAC problems (dirty, moist filters, poor condensation drainage)
Dryer vented indoors, inadequate ventilation for a kitchen, bath or other high moisture area
Any source of condensation

Mold Areas: Checklist (check all that apply)


Existing Sq. Ft. Cleanup Required by
Mold of Area Client/Building Owner
Bath (location)
Shower
(location)
Kitchen
Laundry area
Basement walls
Crawlspace
Exterior walls
Attic/Ceilings
Other(specify)

Existing mold was found in your home. The mold is located in the areas checked under the Existing Mold
column.

Weatherization work cannot be done until the mold in the areas checked under the Cleanup
Required column has been cleaned up. The client, or building owner, is responsible for the
cleanup.
Any item checked in the Mold Areas column, but not checked in the Cleanup Required column
does not need to be cleaned up prior to weatherization Work. However, it is advisable to clean
up all mold.

Visible evidence of moisture, but no visible evidence of existing mold was found.
Comments:
By signing below, I acknowledge that I have been notified there is existing mold in the home prior to any
weatherization work being done. If the mold has to be cleaned up before weatherization work can begin, I agree to
have it cleaned up and then contact the agency so the weatherization work may proceed.

Customer/Tenant Signature: Date:

Owner Signature: Date:


(If different from customer)

Agency Representative: Date:

Revised

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