Instructions: Provide one completed Physical Needs Assessment Template for each single family home inspected. This template must be completed by a third party inspector who is not affiliated (no Identity of Interest) with the property’s ownership.

General Information	
Date:	  M	  D	    Y	Minnesota Housing Development No. (D)       (if available)	Minnesota Housing Project No. (M)       (if available)	
Property Address:      	City:      	
Needs Assessor/Prepared  By/Inspected By:
Name      
Organization      
Contact (phone)       /       /        (email)         (address)      	

Building Information	
Housing Type      	Single Family	 Duplex 	 Town Home	 Other	Year Built:      	# of Bedrooms:      	
# of Stories (above grade)	     	Fully/Partially 
Accessible?	Yes	No	Basement	Yes	No	Crawl Space	Yes	No	
Construction Material Type	 Wood	 Masonry	 Steel	 Concrete	 Combo	 Other	
Roof Type	 Flat	 <1”:1’	 1”:1’ -8’:12’	 >8’:12’	 Irregular	 Other	
Roof Material	 Asphalt Shingles	 Other Shingles	 Single Membrane	 Built Up	 Metal	 Other	
Air Conditioning	 Central/Packaged	 Window	 Sleeve	 Other	Fire Sprinkler 	Yes	No	
Combustion Equipment 	Is gas space or gas water heating combustion equipment present?                                                          Yes    No 	
	If yes, is all combustion equipment either power-vented or closed/sealed combustion type?             Yes    No    N/A	
Comments
     	

Parking Information/Tabulation	
Type of parking	# of Units	Attached	Detached	Comments	
One stall garage	     			     	
Two stall garage	     				
On-site surface spaces	     				
Off-site street spaces	     				
Total	     				
Life Expectancy – Major Element/Assemblies Summary
A default EUL is included and may be revised to reflect a more accurate EUL if so determined by the Needs Assessor completing this form.	
Element	Type	Expected Useful Age
(EUL) (in years)
(Default Shown)	Estimated Age
(EA) (in years)
(Insert Age)	Effective Remaining Life
(ERL) (in years)
(EUL – EA = ERL)	Comments	
Site – Asphalt/Concrete	     	      (25)	     	     	     	
Roof	     	      (20)	     	     	     	
Windows	     	      (25)	     	     	     	
Exterior Siding and Trim	     	            (10-40)	     	     	     	
Doors – Exterior	     	      (25)	     	     	     	
Doors – Exterior O.H.	     	      (20)	     	     	     	
Doors – Interior	     	      (30)	     	     	     	
Cabinets – Kitchen and Bath	     	      (20)	     	     	     	
Flooring (Carpet)	     	      (07)	     	     	     	
Flooring (Resilient/Vinyl)	     	      (15)	     	     	     	
Flooring (Wood)	     	      (30)	     	     	     	
Flooring (Tile/Concrete)	     	      (50)	     	     	     	
Appliances (Refrigerator)	     	      (15)	     	     	     	
Appliances (Range)	     	      (15)	     	     	     	
Appliances (Dishwasher)	     	      (10)	     	     	     	
Appliances (Clothes Washer)	     	      (14)	     	     	     	
Appliances (Clothes Dryer)	     	      (13)	     	     	     	
Plumbing Fixtures	     	      (20)	     	     	     	
Water Heater(s)	     	      (10)	     	     	     	
HVAC Systems	     	      (25)	     	     	     	
Window/Wall Sleeve AC	     	      (10)	     	     	     	
Lighting	     	      (25)	     	     	     	
Private Well	     	      (?)	     	     	     	
Private Septic	     	      (?)	     	     	     	
Other      	     	     	     	     	     	

Indicate Condition: P = Pass; F = Fail; or I = Inconclusive
1. Structural Integrity	
Item #	Item	Condition	Comments	
		P	F	I		
1.1	No signs of imminent structural failure or collapse				     	
1.2	Decks or porches				     	
1.3	Basement Columns				     	
1.4	Foundations				     	
1.5	Floors/Subfloors				     	
1.6	Walls				     	
1.7	Roof Framing				     	
1.8	Headers/Lintels				     	
1.9 	Other				     	

2. Building Envelope	
Item #	Item	Condition	Comments	
		P	F	I		
2.1	Weather/Water Tight				     	
2.2	Doors				     	
2.3	Windows				     	
2.4	Insect screens (windows/doors)				     	
2.5	Insulated Properly				     	
2.6	Attic Vented and Insulated				     	
2.7	Overall condition of crawl space. Is it conditioned or vented? Does it have a properly installed vapor barrier? Does it appear to be dry? Is there standing water in sump basket (if there is a sump basket)? 				     	
2.8 	Other				     	

3. Site and Roof Drainage 	
Item #	Item	Condition	Comments	
		P	F	I		
3.1	The site is well drained				     	
3.2	No standing water 12 hours after rain event				     	
3.3	Surface drainage is directed away from building				     	
3.4	Surface drainage goes to designated pond or municipal storm sewer system				     	
3.5	Proper roof drainage provided				     	
3.6	Other				     	

4. Overall Interior	
Item #	Item	Condition	Comments	
		P	F	I		
4.1	Weather/Water Tight				     	
4.2	Doors				     	
4.3	Windows				     	
4.4	Ceilings				     	
4.5	Walls				     	
4.6 	Other				     	

5. Kitchen	
Item #	Item	Condition	Comments	
		P	F	I		
5.1	Present				     	
5.2	1 outlet/1 light				     	
5.3	Stove/Range				     	
5.4	Refrigerator				     	
5.5	Sink				     	
5.6	Counter/Cabinets				     	
5.7 	Other				     	

6. Living Room	
Item #	Item	Condition	Comments	
		P	F	I		
6.1	Present				     	
6.2	Window				     	
6.3	2 Outlets/1 Light				     	
6.4 	Other				     	

7. Bathroom(s)	
Item #	Item	Condition	Condition	Condition	Comments	
		P	F	I	P	F	I	P	F	I		
7.1	Present										     	
7.2	1 Outlet/1 Light											
7.3	Toilet											
7.4	Lavatory											
7.5	Tub and/or Shower											
7.6 	Mechanical/Natural Ventilation											

8. Bedroom(s)	Bedroom #1	Bedroom #2	Bedroom #3	Bedroom #4	Bedroom #5	>5	
Item #	Item	Condition	Condition	Condition	Condition	Condition	More than 5 Bedrooms
Yes
No	
8.1	Present																	
8.2	1 Outlet/1 Light																	
8.3	Window																	
8.4	Closet																	
Comments:
     	

9. Plumbing and Sanitation Systems 	
Item #	Item	Condition	Comments	
		P	F	I		
9.1	Appear to be code compliant				     	
9.2	Are adequately sized				     	
9.3	Are operable				     	
9.4	Free of visible leaks				     	
9.5	Free of obsolete, inefficient water wasting fixtures				     	
9.6	Sanitary sewer lines open and clog free				     	
9.7	Municipal water connection				     	
9.8	Municipal sanitary sewer connection				     	
9.9	Private well. Indicate when last inspected. 				     	
9.10	Private septic system. Indicate when last inspected.				     	
9.11	Other				     	

10. Mechanical Systems 	
Item #	Item	Condition	Comments	
		P	F	I		
10.1	Appear to be code compliant				     	
10.2	Are adequately sized				     	
10.3	Controls and equipment are operable				     	
10.4	Clothes dryer(s) are exhausted to the exterior with rigid ducts 				     	
10.5	Other				     	

11. Electrical Systems 	
Item #	Item	Condition	Comments	
		P	F	I		
11.1	Appear to be code compliant with circuit breakers				     	
11.2	Adequately sized				     	
11.3	Smoke detectors provided where required by code? Are they hardwired with battery backup?				     	
11.4	If natural gas equipment or appliances are present, a properly installed carbon monoxide (CO) alarm is present				     	
11.5	Cover plates, switches, receptacles, etc. are not missing and are not damaged				     	
11.6	Ground Fault Circuit Interrupters (GFCI) receptacles are provided where required by code and are in working order				     	
11.7	Other				     	

12. Environmental 	
Item #	Item	Condition	Comments	
		P	F	I		
Contamination - Lead	
12.1	Built before 1978				     	
12.2	Built before 1978, but a visual assessment (*conducted by PNA provider trained per HUD protocol) did not identify any deteriorated paint.				     	
Contamination – Visible Mold	
12.3	Free of visible mold				     	
Radon	
12.4	Has the home been tested for radon? 				     	
12.5	If tested, are the results below the action level, or has a mitigation system been installed?				     	
Other Environmental Hazards	
12.6	Other				     	

13. Other Inspections 	
Item #	Item	Condition	Comments	
		P	F	I		
13.1	Are there any known code violations or corrections notices?				     	
13.2	Windows above the first floor are equipped with fall prevention if the sill is over 24” above the room finished floor.				     	
13.3	If a habitable room is located in the basement, a code compliant egress window is provided and in working order.				     	
13.4	Other				     	

14. Accessibility (if applicable)	
Item #	Item	Condition	Comments	
		P	F	I		
14.1	Is this a Type A Accessible dwelling unit?				     	
14.2	Is there a (wheel chair) accessible route to the main entry with a 36” minimum wide door?				     	
14.3	Is there an accessible kitchen with 34” counter heights, required floor clearance, proper appliance controls, etc.?				     	
14.4	Is there an accessible (full) bathroom on an accessible floor level with required grab bars, plumbing fixtures, etc.?				     	
14.5	Is there at least one accessible bedroom on an accessible floor level?				     	
14.6	Other				     	

Other Comments	
Provide more detail for all “Fail” conditions. Attach additional page(s), if needed.
     	

Assessor/Inspector Certification

I certify that this Physical Needs Assessment is a true and accurate representation of the condition of the property as of the date indicated. I also certify that it was prepared by me or under my direct supervision.

     
Printed Name

     
Signature

      (m)       (d)       (year)
Date Inspection Completed

Attachments: