This form/template must be completed by a Licensed Architect, Professional Engineer, Qualified Rehab Specialist, Qualified Needs Assessor, or entity that is not affiliated (no identity of interest) with the property’s ownership, development or management.

General Information	
Date:	  M	  D	    Y	Minnesota Housing Development No. (D)       (if available)	Minnesota Housing Project No. (M)       (if available)	
Project/Development Name:       	
Address:      	City:      	
Needs Assessor/Prepared  By/Inspected By:
Name      
Organization      
Contact (phone, email, address)       /       /      	

Unit Information/Tabulation	Housing Type
check all that apply	
Unit Types	# of Units	SF Each (optional)	Total SF (optional)	
Single Family Detached
 Duplex
Town Home
 Low Rise <5 Stories
 High Rise  5+ Stories
 Manufactured Home
 Congregate
 Cooperative
 Independent Group Residence
 Single Room Occupancy
 Shared Housing
 Workforce Housing
 Supportive Housing
 Other	
E/O BR	    	     	     		
1 BR	    	     	     		
2 BR	    	     	     		
3 BR	    	     	     		
4 BR	    	     	     		
5+ BR	    	     	     		
Unit Subtotal	    	     	     		
					
Common Area		     	     		
Other		     	     		
Common/Other Subtotal		     	     		
					
Total SF		     	     		
		
Number of Buildings:      	Year Built:      	Number of Current Accessible Units
(Type A, Type B and Adaptable):       		
Comments:
     	

Parking Information/Tabulation	
Type of parking	# of Units	Attached	Detached	SF Each (optional)	Total SF (optional)	
One stall garage	     			     	     	
Two stall garage	     			     	     	
Common garage spaces	     			     	     	
On-site surface spaces	     			     	     	
Off-site street spaces	     			     	     	
Total	     			     	     	
Of the total # of parking spaces, how many are Regular Accessible Spaces?        How many are Van Accessible Spaces?      	
Comments: (parking receptacles, etc.)
     	

Building Information	
# of Stories (above grade)	     	Fire Sprinkler 	Yes	No	Basement	Yes	No	Crawl Space	Yes	No	
Construction Material Type	 Wood	 Masonry	 Steel	 Concrete	 Combo	Other	
Roof Type	 Flat	 <1”:1’	 1”:1’ -8’:12’	 >8’:12’	Irregular	 Other	
Roof Material	 Asphalt Shingles	 Other Shingles	 Single Membrane	 Built Up	 Metal	 Other	
Dwelling Unit Air Conditioning	 Central/Packaged	 Tenant Provided	 Property Provided 	 Window 	 Sleeve	 Other	
Combustion Equipment 	Is gas furnace, boiler or water heating combustion equipment present?                                                Yes    No 
If yes, is all combustion equipment either power-vented or closed/sealed combustion type?             Yes    No    N/A	
Comments:
     	

Life Expectancy – Major Element/Assemblies Summary	
This summary must reconcile with Minnesota Housing’s 20-Year Capital Expenditure (20YCE) Template. A default EUL is included and may be revised to reflect a more accurate EUL if determined by the Needs Assessor completing this form.	
In lieu of completing this “Life Expectancy” section, the Minnesota Housing 20YCE Template may be completed and attached.
 Check here if the 20YCE is attached.	
Element	Type	Expected Useful Life
(EUL) (in years)
(Default Shown)	Estimated Age
(EA) (in years)
(Insert Age)	Effective Remaining Life
(ERL) (in years)
(EUL  - EA = ERL)	Comments	
Site – Asphalt/Concrete	     	      (25)	     	     	     	
Site – Accessory Structures	     	      (25)	     	     	     	
Roof	     	      (20)	     	     	     	
Windows	     	      (25)	     	     	     	
Exterior Wall Finish	     	      (15-40)	     	     	     	
Doors – Exterior	     	      (25)	     	     	     	
Doors – Exterior O.H.	     	      (20)	     	     	     	
Doors – Interior	     	      (30)	     	     	     	
Cabinets – Kitchen and Bath	     	      (20)	     	     	     	
Flooring – Common Areas	     	      (07)	     	     	     	
Flooring – Dwelling Units	     	      (07)	     	     	     	
Kitchen Appliances	     	      (15)	     	     	     	
Plumbing Fixtures	     	      (20)	     	     	     	
Water Heater(s)	     	      (10)	     	     	     	
HVAC Systems/ Boilers	     	      (25)	     	     	     	
Water Main/ Sewer Lines	     	      (50)	     	     	     	
Window/Wall Sleeve AC	     	      (10)	     	     	     	
Lighting	     	      (25)	     	     	     	
Fire Alarms/ CO/ NO2	     	      (25)	     	     	     	
Elevator(s)	     	      (25)	     	     	     	
Other	     	              	     	     	     	

Indicate Condition: P = Pass; F = Fail; or I = Inconclusive
Inspectable Area #1
Site and Accessory Structures
Chapter 3, Section 3.05, Item A.2 (c) i – Rental Housing Design/ Construction Standards (RHD/CS)	
Item #	Item	Condition	Comments	
		P	F	I		
6.1	The site is well drained				     	
6.2	No standing water 12 hours after rain event				     	
6.3	Surface drainage is directed away from building				     	
6.4	Surface drainage goes to designated pond or municipal storm sewer system				     	
6.5	Proper roof drainage provided				     	
6.6	Parking is adequately sized for the resident population and is properly striped				     	
6.7	Pavement (parking and walks) is free of raveling, severe cracking, tripping hazards, and “potholes”.				     	
6.8	Accessory Structures are in good condition and free of life safety/ code concerns, including detached garages, sheds, porches, decks, fences, retaining walls, trash enclosures, etc.				     	
6.9	Accessible parking spaces properly identified				     	
6.10	Other      				     	

Inspectable Area #2
Structural Integrity
Chapter 3, Section 3.05, Item A.2 (c) ii – Rental Housing Design/ Construction Standards (RHD/CS)	
Item #	Item	Condition	Comments	
		P	F	I		
7.1	No signs of imminent structural failure or collapse				     	
7.2	Decks or porches				     	
7.3	Basement Columns				     	
7.4	Foundations				     	
7.5	Floors/Subfloors				     	
7.6	Walls				     	
7.7	Roof Framing				     	
7.8	Headers/Lintels				     	
7.9 	Other      				     	

Inspectable Area #3
Building Envelope
Chapter 3, Section 3.05, Item A.2 (c) iii – Rental Housing Design/ Construction Standards (RHD/CS)	
Item #	Item	Condition	Comments	
		P	F	I		
8.1	Weather/Water Tight				     	
8.2	Roof				     	
8.3	Soffits, Fascias, Parapets				     	
8.4	Exterior Walls and Wall Finishes 				     	
8.5	Doors				     	
8.6	Windows/ Skylights				     	
8.7	Insulated Properly				     	
8.8	Attic Vented and Insulated				     	
8.9	Crawl Space Tempered w/ Vapor Barrier				     	
8.10	Foundations				     	
8.11	Other      				     	

Inspectable Area #4
Common Area
Chapter 3, Section 3.05, Item A.2 (c) iv – Rental Housing Design/ Construction Standards (RHD/CS)	
Item #	Item	Condition	Comments	
		P	F	I		
9.1	Attached/ Underground Garages				     	
9.2	Furniture/ Fixtures/ Equipment				     	
9.3	Cabinetry				     	
9.4	Interior Doors/ Windows 				     	
9.5	Flooring				     	
9.6	Walls/ Ceiling (Painting or Patch)				     	
9.7	Public Bath - Accessories				     	
9.8	Public Bath – Plumbing Fixtures				     	
9.9	Stairs				     	
9.10	Other      				     	

Inspectable Area #5
Common Plumbing and Sanitation Systems
Chapter 3, Section 3.05, Item A.2 (c) vi  – Rental Housing Design/ Construction Standards (RHD/CS)	
Item #	Item	Condition	Comments	
		P	F	I		
10.1	Appear to be code compliant				     	
10.2	Are adequately sized				     	
10.3	Are operable				     	
10.4	Free of visible leaks				     	
10.5	Free of obsolete, inefficient, water wasting fixtures				     	
10.6	Sanitary sewer lines open and clog free				     	
10.7	Other      				     	

Inspectable Area #6
Common Area Mechanical Systems 
Chapter 3, Section 3.05, Item A.2 (c) vii – Rental Housing Design/ Construction Standards (RHD/CS)	
Item #	Item	Condition	Comments	
		P	F	I		
11.1	Appear to be code compliant				     	
11.2	Are adequately sized				     	
11.3	Controls and equipment are operable				     	
11.4	Kitchen exhaust meets the current MN Overlay and Enterprise Green Communities Criteria				     	
11.5	All bathrooms have operable exhaust which meets the current MN Overlay and Enterprise Green Communities Criteria 				     	
11.6	Clothes dryer(s) are exhausted to the exterior with rigid ducts 				     	
11.7	Common areas have AC				     	
11.8	Common ventilation system is working properly and not abandoned				     	
11.9	Other      				     	

Inspectable Area #7
Common Area Electrical Systems
Chapter 3, Section 3.05, Item A.2 (c) viii  – Rental Housing Design/ Construction Standards (RHD/CS)	
Item #	Item	Condition	Comments	
		P	F	I		
12.1	Appear to be code compliant with circuit breakers				     	
12.2	Receptacles, switches, lighting, are adequately sized and located.				     	
12.3	Smoke Alarm/ Fire Alarm/ CO/ NO2  are up to code and fully operational				     	
12.4	Other      				     	

Inspectable Area #8
Elevator (if present)
Chapter 3, Section 3.05, Item A.2 (c) ix  – Rental Housing Design/ Construction Standards (RHD/CS)	
Item #	Item	Condition	Comments	
		P	F	I		
13.1	Is an elevator provided?				     	
13.2	Is it in compliance with the current MN Elevator Code?				     	
13.3	Is every level of each building accessible by elevator?				     	
13.4	Is maximum travel length to an elevator less than 250 lineal feet?				     	
13.5	Other      				     	
13.6	How many elevators are there?	     	     	

Inspectable Area #9
Fire Protection
Chapter 3, Section 3.05, Item A.2 (c) x – Rental Housing Design/ Construction Standards (RHD/CS)	
Item #	Item	Condition	Comments	
		P	F	I		
14.1	If sprinklers are on site, are they operable and  code compliant				     	
14.2	Are required fire extinguishers present and in working order				     	
14.3	Other      				     	

Inspectable Area #10
Environmental
Chapter 3, Section 3.05, Item A.2 (c) xi – Rental Housing Design/ Construction Standards (RHD/CS)	
Item #	Item	Condition	Comments	
		P	F	I		
15A. Contamination –  Lead	
15A.1	Built before 1978?				     	
15A.2	Built before 1978, but a visual assessment (conducted by PNA provider trained per HUD protocol) did not detect any deteriorated paint				     	
15B. Contamination – Mold/ Mildew	
15B.1	There are no visible signs of mold or mildew				     	
15C. Radon	
15C.1	Has a Radon test been conducted				     	
15C.2	A Radon test results indicated levels below the action level of 4 pC/l. 				     	
15D. Asbestos Containing Material	
15D.1	A suspect asbestos containing material,  or asbestos survey, or asbestos O&M available				     	
Other Environmental	
15D.2	Are there any Underground Storage Tanks				     	
15D.3	Are there any Response Action Plans or other site environmental issues				     	
15D.4	Other      				     	

Inspectable Area #11
Accessibility
Chapter 3, Section 3.05, Item A.2 (c) xii – Rental Housing Design/ Construction Standards (RHD/CS)	
Item #	Item	Condition	Comments	
		P	F	I		
16.1	The site and all common areas are accessible as per applicable requirements, including accessible routes				     	
16.2	There are no resident requests for reasonable accommodations at common areas				     	
16.3	All dwelling units are accessible to the maximum extent feasible or, separate Accessibility Analysis and Survey has been prepared				     	
16.4	Other      				     	

Inspectable Area #12
Other Inspections 
(RHD/CS Chapter 3)	
Item #	Item	Condition	Comments	
		P	F	I		
17.1	The local building inspector has been engaged and/or local code issues have been identified.				     	
17.2	A building code analysis and/or ordinance review has been prepared.				     	
17.3	Other      				     	

Other Comments	
Provide more information and detail for “F (Failure)” Conditions. Attach additional page(s) if needed.
     	

Inspect 25% of the Dwelling Units. See Chapter 3, Section 3.05, Item A.2 of the Rental Housing Design/Construction Standards.
Inspectable Area #13(a). Dwelling Unit Inspection	
General Info	Item #	1	2	3	4	5	6	7	8	9	10	11	12	13	14	15	16	17	18	19	20	
	Unit/Apartment #	     	     	     	     	     	     	     	     	     	     	     	     	     	     	     	     	     	     	     	     	
	# of Bedrooms	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	
	Accessible (Y/N)	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	
	Floor Level 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	
Indicate:  P = Pass   F = Fail   I = Incomplete	Overall	 Walls	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	
		 Ceilings	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	
		 Floors	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	
		 No Deteriorating Paint	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	
	Living Room	 Present	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	
		 Window	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	
		 2 outlets / 1 Light	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	
	Kitchen	 Present	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	
		 1 Outlet / 1 Light	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	
		 Stove	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	
		 Refrigerator	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	
		 Sink	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	
		 Counter / Cabinets	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	
	Bed Room	 1 Outlet / 1 Light	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	
		 Window	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	
		 Closet	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	
	Bath Room	 Present	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	
		 1 Outlet / 1 Light	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	
		 Toilet	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	
		 Lavatory	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	
		 Tub or Shower	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	
		 Ventilation to Exterior	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	
	Mech. HVAC	 Code Compliant	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	
		 Adequately Sized	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	
		 Dryer Vent to Exterior	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	
		 AC/AC Sleeve	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	
	Plumbing
Fixtures	 Code Compliant	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	
		 Adequately Sized	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	
		 No Leaks or Clogs	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	
		 Working Order	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	
	Electrical	 Smoke Detectors	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	
		 GFI/Arc-Fault	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	
		 CO Detectors	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	
Comments/ Other:      	

Inspect 25% of the Dwelling Units. See Chapter 3, Section 3.05, Item A.2 of the Rental Housing Design/Construction Standards.

Inspectable Area #13(b). Dwelling Unit Inspection (continuation)	
General Info	Item #	21	22	23	24	25	26	27	28	29	30	31	32	33	34	35	36	37	38	39	40	
	Unit/Apartment #	     	     	     	     	     	     	     	     	     	     	     	     	     	     	     	     	     	     	     	     	
	# of Bedrooms	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	
	Accessible (Y/N)	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	
	Floor Level 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	
Indicate:  P = Pass   F = Fail   I = Incomplete	Overall	 Walls	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	
		 Ceilings	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	
		 Floors	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	
		 No Deteriorating Paint	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	
	Living Room	 Present	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	
		 Window	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	
		 2 outlets / 1 Light	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	
	Kitchen	 Present	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	
		 1 Outlet / 1 Light	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	
		 Stove	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	
		 Refrigerator	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	
		 Sink	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	
		 Counter / Cabinets	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	
	Bed Room	 1 Outlet / 1 Light	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	
		 Window	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	
		 Closet	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	
	Bath Room	 Present	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	
		 1 Outlet / 1 Light	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	
		 Toilet	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	
		 Lavatory	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	
		 Tub or Shower	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	
		 Ventilation to Exterior	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	
	Mech. HVAC	 Code Compliant	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	
		 Adequately Sized	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	
		 Dryer Vent to Exterior	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	
		 AC/AC Sleeve	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	
	Plumbing
Fixtures	 Code Compliant	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	
		 Adequately Sized	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	
		 No Leaks or Clogs	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	
		 Working Order	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	
	Electrical	 Smoke Detectors	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	
		 GFI/Arc-Fault	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	
		 CO Detectors	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	
Comments/ Other:      	

Inspect 25% of the Dwelling Units. See Chapter 3, Section 3.05, Item A.2 of the Rental Housing Design/Construction Standards.

Inspectable Area #13(c). Dwelling Unit Inspection (continuation)	
General Info	Item #	41	42	43	44	45	46	47	48	49	50	51	52	53	54	55	56	57	58	59	60	
	Unit/Apartment #	     	     	     	     	     	     	     	     	     	     	     	     	     	     	     	     	     	     	     	     	
	# of Bedrooms	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	
	Accessible (Y/N)	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	
	Floor Level 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	
Indicate:  P = Pass   F = Fail   I = Incomplete	Overall	 Walls	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	
		 Ceilings	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	
		 Floors	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	
		 No Deteriorating Paint	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	
	Living Room	 Present	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	
		 Window	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	
		 2 outlets / 1 Light	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	
	Kitchen	 Present	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	
		 1 Outlet / 1 Light	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	
		 Stove	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	
		 Refrigerator	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	
		 Sink	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	
		 Counter / Cabinets	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	
	Bed Room	 1 Outlet / 1 Light	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	
		 Window	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	
		 Closet	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	
	Bath Room	 Present	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	
		 1 Outlet / 1 Light	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	
		 Toilet	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	
		 Lavatory	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	
		 Tub or Shower	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	
		 Ventilation to Exterior	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	
	Mech. HVAC	 Code Compliant	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	
		 Adequately Sized	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	
		 Dryer Vent to Exterior	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	
		 AC/AC Sleeve	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	
	Plumbing
Fixtures	 Code Compliant	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	
		 Adequately Sized	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	
		 No Leaks or Clogs	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	
		 Working Order	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	
	Electrical	 Smoke Detectors	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	
		 GFI/Arc-Fault	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	
		 CO Detectors	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	
Comments/ Other:      	

Comments:
Provide more detail for all “Fail” conditions. Attach additional page(s), if needed.  
     	

Assessor/Inspector Certification

I certify that this Physical Needs Assessment is a true and accurate representation of the condition of the property as of the date indicated. I also certify that it was prepared by me or under my direct supervision.

     
Printed Name

     
Signature

      (m)       (d)       (year)
Date Inspection Completed

Attachments: