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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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