Habitability Issues Survey | Inland Equity Community Land Trust

Name

Email

Phone

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

	Do you Have a Lease or a Written Rental Agreement?
Yes	Yes
No	No

	ELECTRICAL
SystSystem is unstableem is unstable	SystSystem is unstableem is unstable
Circuit breakers blow	Circuit breakers blow
Wall switches Not working	Wall switches Not working
Cover plates broke or missing	Cover plates broke or missing
Sparking Light fixtures	Sparking Light fixtures
Lights Flickering/intermittent	Lights Flickering/intermittent
Lights Not working	Lights Not working
Inadequate lightingInadequate lighting	Inadequate lightingInadequate lighting
Light dangling - Not secured properly	Light dangling - Not secured properly
Common grounds lighting insufficient	Common grounds lighting insufficient
Electrical outlets not working - Electric shock from any part Missing cover plates Exposed wiring Sparking One socket not working Loose socket Plug falls out Indoor outlets near water are not GFI Outdoor outlets are not GFI	Electrical outlets not working - Electric shock from any part Missing cover plates Exposed wiring Sparking One socket not working Loose socket Plug falls out Indoor outlets near water are not GFI Outdoor outlets are not GFI
Fans not working - Ceiling/circulation Portable/window fans Heater [e.g., bathroom] Above stove	Fans not working - Ceiling/circulation Portable/window fans Heater [e.g., bathroom] Above stove
Smoke alarms - Too sensitive/always sounding Not working at all	Smoke alarms - Too sensitive/always sounding Not working at all
Doorbell does not work	Doorbell does not work
Security system does not work	Security system does not work

	COMMON AREAS ~ Specify in "Add Notes" field
Recreation room	Recreation room
Gym	Gym
Mailbox	Mailbox
Parking area	Parking area
Broken security gate	Broken security gate
Flooding	Flooding
Swimming Pool/jacuzzi - No fence around pool Missing safety devices Inadequately lit Leaks Pump/filter broken No circulation Will not heat Algae accumulation Chipped tile	Swimming Pool/jacuzzi - No fence around pool Missing safety devices Inadequately lit Leaks Pump/filter broken No circulation Will not heat Algae accumulation Chipped tile
Elevator	Elevator
Laundry room - Machines do not work Inadequately lit Filthy with debris/trash	Laundry room - Machines do not work Inadequately lit Filthy with debris/trash
Inadequate trash bins/pickup	Inadequate trash bins/pickup
Trash/debris/junk around grounds	Trash/debris/junk around grounds

	STRUCTURE
Ceiling - Falling down/collapsing - Sagging/damp/soft spots - Holes - Flaking - Looseness - Leaks/stains from rain - Leaks/stains from plumbing	Ceiling - Falling down/collapsing - Sagging/damp/soft spots - Holes - Flaking - Looseness - Leaks/stains from rain - Leaks/stains from plumbing
Walls - Weak/loose/unconnected - Holes/gaps - Missing wall surface - Studs exposed - Damp/soft spots	Walls - Weak/loose/unconnected - Holes/gaps - Missing wall surface - Studs exposed - Damp/soft spots
Inadequate insulation	Inadequate insulation
Inadequate soundproofing	Inadequate soundproofing
Exterior walls not sealed	Exterior walls not sealed
Unstable basement walls	Unstable basement walls
Stairways - rails are Insecure - unsafe railings - steps dilapidated and failing	Stairways - rails are Insecure - unsafe railings - steps dilapidated and failing
Exterior porch or deck - Uneven, unstable, holes or rotting	Exterior porch or deck - Uneven, unstable, holes or rotting

	APPLIANCES
Stove	Stove
Refrigerator	Refrigerator
Dishwasher	Dishwasher
Clothes washer/dryer	Clothes washer/dryer
Trash compactor	Trash compactor
Garbage disposal	Garbage disposal

	WINDOWS
Inadequate number of windows	Inadequate number of windows
Inadequate ventilation	Inadequate ventilation
Cracked/broken glass	Cracked/broken glass
Gaps in panes/windows	Gaps in panes/windows
Inadequate weather stripping	Inadequate weather stripping
Windows that should open - Do not open easily - Do not stay open - Do not close completely - Do not latch - Stick	Windows that should open - Do not open easily - Do not stay open - Do not close completely - Do not latch - Stick
Ground floor windows have no lock	Ground floor windows have no lock
Window screens - Holes/tears - Missing from some/all - Frames bent/broken: Some jurisdictions have a local ordinance	Window screens - Holes/tears - Missing from some/all - Frames bent/broken: Some jurisdictions have a local ordinance

	DOORS
Interior doors - Door Knob/lock broken - Loose in frame/maladjusted - Stick - Will not close securely - Door Knob/latches missing	Interior doors - Door Knob/lock broken - Loose in frame/maladjusted - Stick - Will not close securely - Door Knob/latches missing
Exterior doors - Door broken - Handle/lock broken - Door does not lock - Key does not work well - Loose in frame/maladjusted - Sticks - Will not close securely - Missing knobs, latches, or deadbolts - Inadequate weather stripping - Threshold is broken - Cracked or broken glass	Exterior doors - Door broken - Handle/lock broken - Door does not lock - Key does not work well - Loose in frame/maladjusted - Sticks - Will not close securely - Missing knobs, latches, or deadbolts - Inadequate weather stripping - Threshold is broken - Cracked or broken glass
Sliding glass doors - Do not completely close - Will not lock securely - Do not latch - Loose in track or Sticks - Cracked/broken glass	Sliding glass doors - Do not completely close - Will not lock securely - Do not latch - Loose in track or Sticks - Cracked/broken glass
Exterior screen doors - Improperly mounted - Will not close fully/properly - Will not latch/lock - Loose in track - Frame bent/broken - Holes/tears in screen - Cannot be secured open	Exterior screen doors - Improperly mounted - Will not close fully/properly - Will not latch/lock - Loose in track - Frame bent/broken - Holes/tears in screen - Cannot be secured open

	HEATING/AIR CONDITIONING
Furnace / Heater - Does not work or is missing - Thermostat broken - Inadequate/no heat - Pilot goes out - Produces odor or is noisy during operation - Ducts Broken - Asbestos in ducts - Air filters failed - Vents do not work	Furnace / Heater - Does not work or is missing - Thermostat broken - Inadequate/no heat - Pilot goes out - Produces odor or is noisy during operation - Ducts Broken - Asbestos in ducts - Air filters failed - Vents do not work
Other heaters not working - Heat lamps - Wall heaters - Portable units	Other heaters not working - Heat lamps - Wall heaters - Portable units
Air conditioning - Central air does not work - Window unit does not work - Inadequate cooling Noisy - Thermostat does not work	Air conditioning - Central air does not work - Window unit does not work - Inadequate cooling Noisy - Thermostat does not work

	PLUMBING
Hot and cold water - No Water at all or Insufficient hot water - Pressure varies/sudden bursts	Hot and cold water - No Water at all or Insufficient hot water - Pressure varies/sudden bursts
Dirty or Unsanitary Water - Contaminated - Rust/discoloration - Odors - Bad taste [e.g., sewage]	Dirty or Unsanitary Water - Contaminated - Rust/discoloration - Odors - Bad taste [e.g., sewage]
Inadequate drainage - Backs up into sink - Backs up into shower/bathtub - Slow drainage	Inadequate drainage - Backs up into sink - Backs up into shower/bathtub - Slow drainage
Toilets - Slow fill and flush - Sewage backups/overflows - Flushing mechanism broken	Toilets - Slow fill and flush - Sewage backups/overflows - Flushing mechanism broken
Leaks - From water line to wall - From base on the floor - From fixture itself	Leaks - From water line to wall - From base on the floor - From fixture itself

	FLOORING
Holes in floor	Holes in floor
Separating from wall	Separating from wall
Weak/loose floorboards Buckling/uneven	Weak/loose floorboards Buckling/uneven
Loose/chipped/missing tiles or linoleum	Loose/chipped/missing tiles or linoleum
No Flooring	No Flooring
Carpeting - Nails sticking up through carpet - Exposed tack strips - Mildewed/moldy - Stinks/unsanitary - Torn/frayed/loose - Trip hazard	Carpeting - Nails sticking up through carpet - Exposed tack strips - Mildewed/moldy - Stinks/unsanitary - Torn/frayed/loose - Trip hazard

	NUISANCES
Infestations - Mice/rats/rodents - Cockroaches - Ants - Bed bugs - Spiders - Termites - Bees/wasps/hornets - Flies/mosquitos - Pigeons/bats - Racoons/opossums - Great White Sharks	Infestations - Mice/rats/rodents - Cockroaches - Ants - Bed bugs - Spiders - Termites - Bees/wasps/hornets - Flies/mosquitos - Pigeons/bats - Racoons/opossums - Great White Sharks
Mold/mildew/mushrooms	Mold/mildew/mushrooms
Raw sewage on exterior ground	Raw sewage on exterior ground
Noxious fumes from sewer - from sewer or other toxic/noxious fumes - Smoke from neighbors in building Chemicals/paints - contamination	Noxious fumes from sewer - from sewer or other toxic/noxious fumes - Smoke from neighbors in building Chemicals/paints - contamination
Unruly neighbors/pets	Unruly neighbors/pets
Criminal Activity - Drug trafficking on the premises - Gang activity on the premises - Criminal acts by other tenants - Assault/molestation - Violent crimes - Prostitution in nearby units	Criminal Activity - Drug trafficking on the premises - Gang activity on the premises - Criminal acts by other tenants - Assault/molestation - Violent crimes - Prostitution in nearby units
Noise - Construction in the building - Neighbors quarreling/stomping - Noisy functions in the building - Noise from adjacent property	Noise - Construction in the building - Neighbors quarreling/stomping - Noisy functions in the building - Noise from adjacent property
Hazards to health - Specify in "Add Notes" field	Hazards to health - Specify in "Add Notes" field
Offensive to the senses - Specify in "Add Notes" field	Offensive to the senses - Specify in "Add Notes" field
Blocks movement - Specify in "Add Notes" field	Blocks movement - Specify in "Add Notes" field
Drug trafficking on the premises	Drug trafficking on the premises
Gang activity on the premises	Gang activity on the premises
Criminal acts by other tenants - Assault/molestation Violent crimes Prostitution in nearby units	Criminal acts by other tenants - Assault/molestation Violent crimes Prostitution in nearby units

Add Notes

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