Form HUD 96001 HUD 96001 Comprehensive Needs Assessment Unit Survey

Comprehensive Needs Assessment
Unit Survey

U.S. Department of Housing
and Urban Development
OMB Approval No.2502-0505 (exp.11/30/2003)
of the Housing and Community Development
Act of 1992, as amended by the Multifamily
Housing Property Disposition Reform of 1994
and Section 531 of the Departments of Veterans
Affairs and Housing and Urban Development,
and Independent Agencies Appropriations Act,
1998, P.L. 105-65, 1998. The Comprehensive
Needs Assessment is a description of current
and future financial resources and needs of
certain multifamily projects. This information
will be used by the Department to assess the
amounts of grant assistance. Failure to provide
the information requested on this form will result
in a delay or rejection of your receiving grant
assistance. Disclosure of this information is
voluntary.

Public Reporting Burden for this collection of
information is estimated to average 1.25 hours
per response, including the time for reviewing
instructions, searching existing data sources,
gathering and maintaining the data needed, and
completing and reviewing the collection of
information. Send comments regarding this
burden estimate or any other aspect of this
collection of information, including suggestions
for reducing this burden, to the Office of
Management and Budget, Paperwork Reduction
Project (2502-0505), Washington, DC 20503.
Do not send this completed form to either of
the above addresses.
Authority: The United States Department of
Housing and Urban Development (HUD) is
authorized to collect this information by Title IV

Dear resident:
Please fill in the survey for your apartment and the project in general. Your input into this process
is the only way to be sure that your needs are taken into account. The Comprehensive Needs
Assessment process is a special inspection to help determine the upkeep plan of the building for the next
20 years.
The U.S. Department of Housing and Urban Development appreciates your help in gathering this
information. Please note, though, that there are no promises about what repairs will be made to your
project or to your apartment, or when they will be made. Not all projects can be repaired at the same
time, so some projects will have repairs made before others can be helped.

Basic Identification
1

Project Name and
Address

2

Building

3

Apartment (unit) Number

4

Date completed

1
Form HUD-96001 (4/01)

Comprehensive Needs Assessment
Unit Survey

U.S. Department of Housing
and Urban Development
OMB Approval No.2502-0505 (exp.11/30/2003)

Are there needed repairs or things that need replacing? Please check the items as needed:
Check N/A if the item does not exist.
1. Unit Access
Outside Front Door (Unit)
Outside Rear Door (Unit)
Outside Rear Screen Door (Unit)
Sliding Glass Door (Unit)
Sliding Screen Door (Unit)
Patio/Balcony
Other
2. Kitchen
Windows, Screens
Flooring
Electrical & Light Fixtures
Ceiling
Doors
Walls & Baseboards
Cabinets & Shelves
Counter Top & Drawers
Plumbing/Sinks/Faucets
Range
Refrigerator
Disposal Unit
Other (Please specify)

OK

Repair

N/A

3. Living Room
Windows, Screens
Flooring
Electrical & Light Fixtures
Ceiling
Doors
Walls & Baseboards
A/C & Heating System
Other (Please specify)
4 Bedroom One
Windows, Screens
Flooring
Electrical & Light Fixtures
Ceiling
Doors
Walls & Baseboards
Closets
Other (Please specify)

2
Form HUD-96001 (4/01)

Comprehensive Needs Assessment
Unit Survey

U.S. Department of Housing
and Urban Development
OMB Approval No.2502-0505 (exp.11/30/2003)

Are there needed repairs or things that need replacing? Please check the items as needed:
Check N/A if the item does not exist.
5. Bedroom Two
Windows, Screens
Flooring
Electrical & Light Fixtures
Ceiling
Doors
Walls & Baseboards
Closets
Other (Please specify)

OK

Repair

N/A

6. Bedroom Three
Windows, Screens
Flooring
Electrical & Light Fixtures
Ceiling
Doors
Walls & Baseboards
Closets
Other (Please specify)
7. Bedroom Four
Windows, Screens
Flooring
Electrical & Light Fixtures
Ceiling
Doors
Walls & Baseboards
Closets
Other (Please specify)
8. Bathroom One
Windows, Screens
Flooring
Electrical & Light Fixtures
Ceiling
Doors
Walls & Baseboards
Cabinets & Shelves
Counter Top & Drawers
Plumbing/Sinks/Faucets
Bath Tub & Shower
Toilets/Mirrors
Towel & Tissue Bars
Hot Water & Water Heater
Other (Please specify)

3
Form HUD-96001 (4/01)