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 / OtherKitchen
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