Checked / Needs
Attention
√ / √

Place a check mark in each area that has been evaluated and mark areas that need attention. Use
”COMMENTS” for notes. Pay attention to your senses – particularly to what you both see and smell.
For the most favorable indoor environment, observe levels of gases, particles, and biopollutants.

Cleaning and maintenance activities must focus first on cleaning for health, and then appearance.

Checked / Needs
Attention
Comments
  1. BUILDING USAGE, EXTERIOR AND NEIGHBORS

No changes in building usage
No construction, renovation or other structural changes
No construction, renovation or other changes affecting neighbors
No evidence of standing water on roofs, parking lots or grounds
No evidence of standing water on neighboring roofs, parking lots or grounds
Potential vehicular traffic issues
  1. BASEMENTS AND CRAWL SPACES

No evidence of moisture or standing water
No evidence of biological contamination (molds, mildew)
Drains and sumps appear to be operational.
No evidence of high levels of dust or debris
No evidence of insects, rodents or other pests
No evidence of dirty or ineffective air filters, pumps, back draft dampers or fans
No sources of VOCs (e.g. stored chemicals)
No noticeable odors
No evidence of cracks in flooring or foundation
  1. GARAGES, LOADING DOCKS AND SHOP AREAS

No evidence of excessive dust, trash and debris
Materials (e.g. paints, chemicals, fuels) are organized and VOCs are controlled through adequate ventilation (e.g. direct exhaust).
Floors are clean to prevent tracking and floor matting systems are utilized and in good working order.
Vehicular exhaust is NOT impacting fresh air intakes.
Dumpster areas are clean and located away from fresh air intakes.
No evidence of insects, rodents or other pests.
  1. ENTRANCES AND LOBBIES

Entrance mats and floor grills are clean and in good working order.
Furthermore they cover enough to be effective (first 9 to 12 feet).
Waste receptacles are cleaned and emptied.
Carpets are clean and in good condition.
Hard floors are clean, dust free and in good condition
Glass doors, decorative surfaces, mirrors and bright work are clean and in good condition.
Window coverings (e.g. draperies, curtains) are clean.
Checked / Needs
Attention
Comments
  1. STAIRS AND ELEVATORS

Carpeting and flooring are clean and in good condition
Bright work and hand rails are clean and in good condition
Steps and landings are clean and free of trash and debris
  1. OFFICES, WORK SPACES, CLASS ROOMS AND LIVING AREAS

Flooring and carpets are clean and in good condition.
Dust levels minimal. Dusting performed with damp cloths or micro-fiber clothes.
Office partitions (especially if fabric covered) are clean and dust free.
Ceiling tiles exhibit no evidence of water or moisture damage.
Telephones, door knobs and light switches are clean and disinfected.
Window and light fixtures are cleaned and operating properly.
Draperies and blinds are clean and dust free.
Trash receptacles are accessible and emptied.
Plants exhibit no evidence of insect infestation, and surfaces under plants are clean.
No evidence of mold, mildew or other biocontamination.
No evidence of insects, rodents or other pests.
Self contained heating and cooling unites are clean, free of biocontamination and operating correctly.
  1. CLASS ROOM #

Flooring and carpets are clean and in good condition.
Dust levels minimal. Dusting performed with damp cloths or micro-fiber clothes.
Office partitions (especially if fabric covered) are clean and dust free.
Ceiling tiles exhibit no evidence of water or moisture damage.
Telephones, door knobs and light switches are clean and disinfected.
Window and light fixtures are cleaned and operating properly.
Draperies and blinds are clean and dust free.
Trash receptacles are accessible and emptied.
Plants exhibit no evidence of insect infestation, and surfaces under plants are clean.
No evidence of mold, mildew or other biocontamination.
No evidence of insects, rodents or other pests.
Self contained heating and cooling unites are clean, free of biocontamination and operating correctly.

NOTES:

Checked / Needs
Attention
Comments
  1. CLASS ROOM #

Flooring and carpets are clean and in good condition.
Dust levels minimal. Dusting performed with damp cloths or micro-fiber clothes.
Office partitions (especially if fabric covered) are clean and dust free.
Ceiling tiles exhibit no evidence of water or moisture damage.
Telephones, door knobs and light switches are clean and disinfected.
Window and light fixtures are cleaned and operating properly.
Draperies and blinds are clean and dust free.
Trash receptacles are accessible and emptied.
Plants exhibit no evidence of insect infestation, and surfaces under plants are clean.
No evidence of mold, mildew or other biocontamination.
No evidence of insects, rodents or other pests.
Self contained heating and cooling unites are clean, free of biocontamination and operating correctly.
  1. SPECIAL AREAS (e.g. SMOKING AREAS, POOLS, LABORATORIES

Chemicals are stored properly and vented directly outdoors.
Smoking areas are vented directly outdoors.
Trash receptacles are accessible and emptied.
No evidence of mold, mildew or other biocontamination.
Dust levels are minimal. Dusting performed with damp cloths.
Flooring and carpets are clean and in good condition.
  1. FOOD PREPARATION AND EATING AREAS

Floors are clean, free of food scraps, debris or any signs of biocontamination, and cleaned at least once daily.
Floor drains are operating properly.
Air vents are clean and operating properly.
All surfaces that come in contact with food preparation are clean, free of food scraps and debris, and cleaned after every meal or use.
Tables (tops and undersides) and chairs are cleaned and sanitized after every meal or use.
Washing areas and appliances, cooking and eating utensils are cleaned after every meal or use.
Trash receptacles are tightly covered and emptied daily.
No evidence of insects, rodents or biocontamination.

NOTES:

Checked / Needs
Attention
Comments
  1. WASHROOMS, RESTROOMS, SHOWER AND BATH AREAS

Floors, countertops, basins and toilets are disinfected/sanitized daily.
Floor drains are operating properly.
No noticeable odors or visible biocontamination (mold & mildew)
Shower heads, water faucets and toilets are operating properly.
Soap dispensers are operating properly.
Vents are clean and operating properly with enough ventilation to keep areas dry.
Waste containers are emptied daily.
  1. MAIL, COPY AND COMPUTER ROOMS

Equipment is free of dust and debris
Floors are clean
Air vents clean and operating correctly.
Waste containers cleaned and emptied daily.
Light switches and door knobs are clean and free of inks and greases.
  1. CUSTODIAL CLOSETS AND STORAGE AREAS

Area is clean and products are neatly organized
Stored equipment is clean. Equipment is cleaned after every use.
Vacuums fitted with HEPA or appropriate filters.
Mops in good condition.
Observe cleaning and stored chemicals for DOT Hazard placards. If hazardous products are stored, further review is necessary.
Floors should be clean and free of debris.
Drains and washbasins operating properly
Exhaust fans/vents are working properly.
  1. MECHANICAL, ATTICS, UPPER AREAS AND ROOFS

No evidence of water leaks or standing water of roof.
Dust levels and debris are minimal.
No evidence of birds, rodents, insects or biocontamination.
Screens and barriers are in place to prevent pest entry.
Outdoor air intakes are clean and away from sources of contamination (vehicle exhaust, smoke stacks, etc.)
Air handlers and related equipment are routinely inspected and cleaned. Filters are periodically cleaned and replaced.
Mechanical rooms and air plenums not sued for storage.

NOTES:

Housekeeping

Survey Form

Building Location:

Investigators:

Date

3644 East Tamarron Drive

Bloomington, IN 47408

812 / 332-7950

© 2003 The Ashkin Group, LLC