Date:Building:Unit:

TO BE COMPLETED AND KEPT BY THE INSPECTOR

Service History:

The last two pest control services were on ____ and ____.

Issues noted:

______

Other relevant work completed in unit (maintenance or resident support services): ______

Evidence of factors complicating pest management efforts:

____ Over-occupancy

____ Clutter

____ Excessive trash/recycling stored in unit

____ Limitation that will be a barrier to remedying problems:

Housekeeping Inspection Checklist Rev. 12/11

____ Physical

____ Mental

____ Language

____ Literacy

____ Financial

____ Time

Housekeeping Inspection Checklist Rev. 12/11

____ Resident uses foggers or spray pesticides

General Inspection

Walls: free of holes/gaps larger than ¼”YN

Floors: clean and sealedYN

Ceilings: cleaned and sealedYN

Pipes entering/leaving the unit are sealed
against pest entryYN

Plumbing in good repairYN

Door sweeps at the bottom of each door that YNleads to the outside

No condensationYN

Adequate lighting for pest inspectionYN

Proper smoke detector placementYN

Exterior wall penetrations, doors, and
windows sealed against pest entryYN

TO BE COMPLETED BY THE INSPECTOR, COPIED,

AND GIVEN TO RESIDENT

Inspection Result:Good / Fair / Poor PASS FAIL

Follow-upDate:______

Recommended the resident purchase

____ Cleaning supplies (gave Cleaning Supply Shopping List)

____ HEPA Vacuum (provided picture/coupon from local store)

____ Work orders filed. Tracking #: ______, ______

____ Pest management professional service requested

Pest Evidence / Roaches / Rodents / Bed Bugs / Molds / Other
Kitchen
Bathroom
Living room
Bedroom 1
Bedroom 2

IF FAIL, there will be a follow-up inspection on ______to check for compliance with the following requests:

Bedroom(s)

____ Reduce/organize clutter

____ Vacuum/sweep/mop floor

____ Dust surfaces

____ Organize clothes (hanging or in drawers/containers/bags)

____ Pull bed at least 4” away from walls and surroundingfurniture

Living room

____ Reduce/organize clutter

____ Vacuum/sweep/mop floor

____ Dust surfaces

____ Organize clothes (hanging or in drawers/containers/bags)

____ Pull furniture 4” away from walls

____ Vacuum upholstered furniture

____ Wash dirty dishes

Kitchen

____ Vacuum/sweep/mop floor

____ Wash all counters

____Store food in pest-proof/cleanable containers(bulk food off the floor enough to sweep under and around)

____Clean stove: top, drip pans, under top, outside, backsplash, exhaust fan

____Clean the surface, inside and under countertop appliances (toaster, microwave, etc.)

____Clean the outside surfaces (including seals) of refrigerator/freezers.

____ Remove items stored next to the refrigerator

____Clean behind and under major appliances: stove, refrigerator, washer/dryer, chest freezer

____ Remove trash/recycling (plastic bags, bottles, cans, paper, and cardboard)

____ Wash dirty dishes

____Throw away expired/spoiled food

____ Empty and clean cupboards

Bathroom

____ Vacuum/sweep/mop floor

____ Remove mold/mildew

Exterior

____ Trim plants so none are within 2’ of the building

____ Remove trash/debris outside

____ Remove standing water in______

Completed by: ______

Housekeeping Inspection Checklist Rev. 12/11