Participant's Information

Full Name *

Phone

Email *

Floor Condition (Pass)

Floor Condition (Fail)

Floor Condition (Comments)

Wall Condition (Baseboards) (Pass)

Wall Condition (Baseboards) (Fail)

Wall Condition (Baseboards) (Comments)

Electricity (Pass)

Electricity (Fail)

Electricity (Comments)

Electric Hazards (Pass)

Electric Hazards (Fail)

Electric Hazards (Comments)

Window Condition (Pass)

Window Condition (Fail)

Window Condition (Comments)

Furniture Condition (Pass)

Furniture Condition (Fail)

Furniture Condition (Comments)

Appliances (Pass)

Appliances (Fail)

Ceiling Condition(lights) (Pass)

Ceiling Condition(lights) (Fail)

Ceiling Condition(lights) (Comments)

Home

Completed by

Date

Odor: Pass Fail

FOSTERING NEW BEGINNING

Odor: Pass Fail

Floor Condition (Pass)

Floor Condition (Fail)

Floor Condition (Comments)

Wall Condition (Baseboards) (Pass)

Wall Condition (Baseboards) (Fail)

Wall Condition (Baseboards) (Comments)

Electricity (Pass)

Electricity (Fail)

Electricity (Comments)

Electric Hazards (Pass)

Electric Hazards (Fail)

Electric Hazards (Comments)

Window Condition (Pass)

Window Condition(Fail)

Window Condition (Comments)

Cookware(plates, forks, pots, etc.)

Cookware(plates,forks,pots,etc.) (Fail)

Cookware(plates,forks,pots,etc.)(Comments)

Appliances (Pass)

Appliances (Fail)

Appliances (Comments)

Ceiling Condition(lights) (Pass)

Ceiling Condition(lights) (Fail)

Ceiling Condition (lights) (Comments)

Sink Drainage and Garbage Disposal (Pass)

Sink Drainage and Garbage Disposal (Fail)

Sink Drainage and Garbage Disposal (Comments)

Counter and Cabinets (in & out) (Pass)

Counter and Cabinets (in & out) (Fail)

Counter and Cabinets (in & out) (Comments)

Garbage Can Condition (Pass)

Garbage Can Condition (Fail)

Garbage Can Condition (Comments)

FOSTERING NEW BEGINNING

3a. Bedroom Name of Occupant:

Odor: X Pass Fail

Linen and Pillows Needed? Y (pillow needed)

Floor Condition (Pass)

Floor Condition (Fail)

Floor Condition (Comments)

Wall Condition (Baseboards) (Pass)

Wall Condition (Baseboards) (Fail)

Wall Condition (Baseboards) (Comments)

Electricity (Pass)

Electricity (Fail)

Electricity (Comments)

Electric Hazards (Pass)

Electric Hazards (Fail)

Electric Hazards (Comments)

Window Condition (Pass)

Window Condition (Fail)

Window Condition (Comments)

Furniture Condition (Pass)

Furniture Condition (Fail)

Furniture Condition (Comments)

Appliances (including all doors and knobs) (Pass)

Appliances (including all doors and knobs) (Fail)

Appliances (including all doors and knobs) (Comments)

Ceiling Condition (lights) (Pass)

Ceiling Condition (lights) (Fail)

Ceiling Condition (lights) (Comments)

FOSTERING NEW BEGINNING

3b. Bedroom Name of Occupant:

Odor: Pass Fail

Linen and Pillows Needed? Y N (No) (need to be cleaned)

Floor Condition (Pass)

Floor Condition (Fail)

Floor Condition (Comments)

Wall Condition (baseboards) (Pass)

Wall Condition (baseboards) (Fail)

Wall Condition (baseboards) (Comments)

Electricity (Pass)

Electricity (Fail)

Electricity (Comments)

Electric Hazards (Pass)

Electric Hazards (Fail)

Electric Hazards (Comments)

Window Condition (Pass)

Window Condition (Fail)

Window Condition (Comments)

Cookware (plates, forks, pots, etc.) (Pass)

Cookware (plates, forks, pots, etc.) (Fail)

Cookware (plates, forks, pots, etc.) (Comments)

Appliances (Oven, stove, microwave, fridge) (Pass)

Appliances (Oven, stove, microwave, fridge) (Fail)

Appliances (Oven, stove, microwave, fridge) (Comments)

Sink Drainage and Garbage Disposal (Pass)

Sink Drainage and Garbage Disposal (Fail)

Sink Drainage and Garbage Disposal (Comments)

Counter and Cabinets (in & out) (Pass)

Counter and Cabinets (in & out) (Fail)

Counter and Cabinets (in & out) (Comments)

Garbage Can Condition (Pass)

Garbage Can Condition (Fail)

Garbage Can Condition (Comments)

Fridge Condition (in & out) (Pass)

Fridge Condition (in & out) (Fail)

Fridge Condition (in & out) (Comments)

FOSTERING NEW BEGINNING

3c. Bedroom Name of Occurant

Odor: Pass Fail

Linen and Pillows Needed? Y N (No) (need to be cleaned)

Bedroom3 Floor Condition (Pass)

Bedroom3 Floor Condition (Fail)

Bedroom3 Floor Condition (Comments)

Bedroom3 Wall Condition (baseboards) (Pass)

Bedroom3 Wall Condition (baseboards) (Fail)

Bedroom3 Wall Condition (baseboards) (Comments)

Bedroom3 Electricity (Pass)

Bedroom3 Electricity (Fail)

Bedroom3 Electricity (Comments)

Bedroom3 Electric Hazards (Pass)

Bedroom3 Electric Hazards (Fail)

Bedroom3 Electric Hazards (Comments)

Bedroom3 Window Condition (Pass)

Bedroom3 Window Condition (Fail)

Bedroom3 Window Condition (Comments)

Bedroom3 Furniture Condition (Pass)

Bedroom3 Furniture Condition (Fail)

Bedroom3 Furniture Condition (Comments)

Bedroom3 Appliances (includingalldoorsandknobs) (Pass)

Bedroom3 Appliances (includingalldoorsandknobs) (Fail)

Bedroom3 Appliances (includingalldoorsandknobs) (Comments)

Bedroom3 Ceiling Condition (lights) (Pass)

Bedroom3 Ceiling Condition (lights) (Fail)

Bedroom3 Ceiling Condition (lights) (Comments)

FOSTERING NEW BEGINNING

3d. Bedroom Name of Occurant

Odor: Pass Fail

Linen and Pillows Needed? Y N

Bedroom4 Floor Condition (Pass)

Bedroom4 Floor Condition (Fail)

Bedroom4 Floor Condition (Comments)

Bedroom4 Wall Condition (baseboards) (Pass)

Bedroom4 Wall Condition (baseboards) (Fail)

Bedroom4 Wall Condition (baseboards) (Comments)

Bedroom4 Electricity (Pass)

Bedroom4 Electricity (Fail)

Bedroom4 Electricity (Comments)

Bedroom4 Electric Hazards (Pass)

Bedroom4 Electric Hazards (Fail)

Bedroom4 Electric Hazards (Comments)

Bedroom4 Window Condition (Pass)

Bedroom4 Window Condition (Fail)

Bedroom4 Window Condition (Comments)

Bedroom4 Furniture Condition (Pass)

Bedroom4 Furniture Condition (Fail)

Bedroom4 Furniture Condition (Comments)

Bedroom4 Appliances (includingalldoorsandknobs) (Pass)

Bedroom4 Appliances (includingalldoorsandknobs) (Fail)

Bedroom4 Appliances (includingalldoorsandknobs) (Comments)

Bedroom4 Ceiling Condition (lights) (Pass)

Bedroom4 Ceiling Condition (lights) (Fail)

Bedroom4 Ceiling Condition (lights) (Comments)

FOSTERING NEW BEGINNING

3e. Bedroom Name of Occupant

Odor: Pass Fail

Linen and Pillows Needed? Y N

Bedroom5 Floor Condition (Pass)

Bedroom5 Floor Condition (Fail)

Bedroom5 Floor Condition (Comments)

Bedroom5 Wall Condition (baseboards) (Pass)

Bedroom5 Wall Condition (baseboards) (Fail)

Bedroom5 Wall Condition (baseboards) (Comments)

Bedroom5 Electricity (Pass)

Bedroom5 Electricity (Fail)

Bedroom5 Electricity (Comments)

Bedroom5 Electric Hazards (Pass)

Bedroom5 Electric Hazards (Fail)

Bedroom5 Electric Hazards (Comments)

Bedroom5 Window Condition (Pass)

Bedroom5 Window Condition (Fail)

Bedroom5 Window Condition (Comments)

Bedroom5 Furniture Condition (Pass)

Bedroom5 Furniture Condition (Fail)

Bedroom5 Furniture Condition (Comments)

Bedroom5 Appliances (includingalldoorsandknobs) (Pass)

Bedroom5 Appliances (includingalldoorsandknobs) (Fail)

Bedroom5 Appliances (includingalldoorsandknobs) (Comments)

Bedroom5 Ceiling Condition (lights) (Pass)

Bedroom5 Ceiling Condition (lights) (Fail)

Bedroom5 Ceiling Condition (lights) (Comments)

FOSTERING NEW BEGINNING

4. Bathroom (Peer Mentor)

Odor: Pass Fail

Linen and Pillows Needed? Y N

Bathroom1 Floor Condition (Pass)

Bathroom1 Floor Condition (Fail)

Bathroom1 Floor Condition (Comments)

Bathroom1 Wall Condition (baseboards) (Pass)

Bathroom1 Wall Condition (baseboards) (Fail)

Bathroom1 Wall Condition (baseboards) (Comments)

Bathroom1 Electricity (Pass)

Bathroom1 Electricity (Fail)

Bathroom1 Electricity (Comments)

Bathroom1 Electric Hazards (Pass)

Bathroom1 Electric Hazards (Fail)

Bathroom1 Electric Hazards (Comments)

Bathroom1 Window Condition (Pass)

Bathroom1 Window Condition (Fail)

Bathroom1 Window Condition (Comments)

Bathroom1 Furniture Condition (Pass)

Bathroom1 Furniture Condition (Fail)

Bathroom1 Furniture Condition (Comments)

Bathroom1 Appliances (includingalldoorsandknobs) (Pass)

Bathroom1 Appliances (includingalldoorsandknobs) (Fail)

Bathroom1 Appliances (includingalldoorsandknobs) (Comments)

Bathroom1 Ceiling Condition (lights) (Pass)

Bathroom1 Ceiling Condition (lights) (Fail)

Bathroom1 Ceiling Condition (lights) (Comments)

FOSTERING NEW BEGINNING

4. Bathroom (Upper Level)

Odor: Pass Fail

Linen and Pillows Needed? Y N

Bathroom2 Floor Condition (Pass)

Bathroom2 Floor Condition (Fail)

Bathroom2 Floor Condition (Comments)

Bathroom2 Wall Condition (baseboards) (Pass)

Bathroom2 Wall Condition (baseboards) (Fail)

Bathroom2 Wall Condition (baseboards) (Comments)

Bathroom2 Electricity (Pass)

Bathroom2 Electricity (Fail)

Bathroom2 Electricity (Comments)

Bathroom2 Electric Hazards (Pass)

Bathroom2 Electric Hazards (Fail)

Bathroom2 Electric Hazards (Comments)

Bathroom2 Window Condition (Pass)

Bathroom2 Window Condition (Fail)

Bathroom2 Window Condition (Comments)

Bathroom2 Furniture Condition (Pass)

Bathroom2 Furniture Condition (Fail)

Bathroom2 Furniture Condition (Comments)

Bathroom2 Appliances (includingalldoorsandknobs) (Pass)

Bathroom2 Appliances (includingalldoorsandknobs) (Fail)

Bathroom2 Appliances (includingalldoorsandknobs) (Comments)

Bathroom2 Ceiling Condition (lights) (Pass)

Bathroom2 Ceiling Condition (lights) (Fail)

Bathroom2 Ceiling Condition (lights) (Comments)

FOSTERING NEW BEGINNING

4. Bathroom (Lower Level)

Odor: Pass Fail

Linen and Pillows Needed? Y N

Bathroom3 Floor Condition (Pass)

Bathroom3 Floor Condition (Fail)

Bathroom3 Floor Condition (Comments)

Bathroom3 Wall Condition (baseboards) (Pass)

Bathroom3 Wall Condition (baseboards) (Fail)

Bathroom3 Wall Condition (baseboards) (Comments)

Bathroom3 Electricity (Pass)

Bathroom3 Electricity (Fail)

Bathroom3 Electricity (Comments)

Bathroom3 Electric Hazards (Pass)

Bathroom3 Electric Hazards (Fail)

Bathroom3 Electric Hazards (Comments)

Bathroom3 Window Condition (Pass)

Bathroom3 Window Condition (Fail)

Bathroom3 Window Condition (Comments)

Bathroom3 Furniture Condition (Pass)

Bathroom3 Furniture Condition (Fail)

Bathroom3 Furniture Condition (Comments)

Bathroom3 Appliances (includingalldoorsandknobs) (Pass)

Bathroom3 Appliances (includingalldoorsandknobs) (Fail)

Bathroom3 Appliances (includingalldoorsandknobs) (Comments)

Bathroom3 Ceiling Condition (Lights) (Pass)

Bathroom3 Ceiling Condition (Lights) (Fail)

Bathroom3 Ceiling Condition (Lights) (Comments)

FOSTERING NEW BEGINNING

5. General Areas

Pest Control Needed? Y N

Lawn maintenance Needed? Y N

Odor: Pass Fail

Follow Up Inspection (if needed): No Yes Date:

General Area Floor Condition (Pass)

General Area Floor Condition (Fail)

General Area Floor Condition(Comments)

General Area Wall Condition (Baseboards) (Pass)

General Area Wall Condition (Baseboards) (Fail)

General Area Wall Condition (Baseboards) (Comments)

General Area Electricity (Pass)

General Area Electricity (Fail)

General Area Electricity (Comments)

General Area Electric Hazards (Pass)

General Area Electric Hazards (Fail)

General Area Electric Hazards (Comments)

General Area Window Condition (Pass)

General Area Window Condition (Fail)

General Area Window Condition (Comments)

General Area Furniture Condition (Pass)

General Area Furniture Condition (Fail)

General Area Furniture Condition (Comments)

General Area Appliances (includingalldoorsandknobs) (Pass)

General Area Appliances (includingalldoorsandknobs) (Fail)

General Area Appliances (includingalldoorsandknobs) (Comments)

FOSTERING NEW BEGINNING