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ITG FY03-4
5 June 2003
APPENDIX C
FACILITIY ASSESSMENT CHECKLIST
Inspection Date: __________________ Building Number: _________________
Inspector:
_____________________ Room: __________________________
Potential Sources of Contamination
Comments
Water Damage To:
 Walls
 Ceiling
 Carpets
Missing Ceiling Tiles/Panels
Visible Mold Growth
Odors, Unsanitary Conditions
Renovation/Construction Activity
HVAC System:
 Number of Units
 State of Repair
 Condition of Supply and
Return Air Grills
 Location of Fresh Air Intakes
 Condition of Filters
Area Condition/Information:
 Temperature
 Humidity
 Chemicals (Solvents,
cleaners, air fresheners)
 Water Leaks
 Housekeeping
 Modular Furniture
 Area Use
 Adjacent Area Use
List any other significant findings:
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