Attachment E_The Home Assessment_Interview Observations

OMB Clearance Number: 2528-0337

Expires: XX/XX/XXXX

Attachment E: The Home Assessment Interviewer Observations

If you require information to be presented in an accessible format or reasonable accommodations to participate in this study, please contact us with any specific requests by calling XXX-XXX-XXXX or emailing [email protected]. If you require language assistance to participate in this study, please contact us with any specific language assistance requests or needs.

  

Paperwork Reduction Act Burden Statement 

This collection of information is voluntary and will be used to evaluate the US Department of Housing and Urban Development’s Community Choice Demonstration. Public reporting burden for this collection of information is estimated to average 10 minutes per response, including the time for reviewing instructions, gathering and maintaining the data needed, and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The OMB number for this collection is OMB 2528-0337 which expires on XX/XX/XXXX. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to NAME at [email protected] or call XXX-XXX-XXXX.  

 

Privacy Act Statement  

Authority:  Section 502 of the Housing and Urban Development Act of 1970 (Public Law 91-609) (12 U.S.C. §§ 1701z-1; 1701z-2(d) and (g)).  

Purpose:  Evaluation of the Community Choice Demonstration (CCD).  

Routine Use:  The information will be used for the purpose set forth above and may be provided to Congress or other Federal, state, and local agencies, when determined necessary.  

Disclosure:  Records will be used for research and statistical analysis and will not be used to make decisions that affect the rights, benefits, or privileges of specific individuals. 

SORN ID:  Community Choice Demonstration Evaluation Data Files, HUD/PDR-09  

 

[To be completed by research team member during site visit]

The Triggers assessment is adapted from: Asthma Education and Intervention Program: Partnership for Asthma Trigger-Free Homes (PATH), https://apps.dtic.mil/sti/pdfs/ADA489872.pdf

Directions (to research team member): Make a checkmark in the box if the problem appears in the room or area listed.

Triggers Assessment		Entryway	Bathroom	Kitchen	Living room	Dining room	Bedroom 1	Bedroom 2	Bedroom 3
Pests	Cockroach sighting
	Rodent sighting
	Hole(s) in wall
	Food storage problems
	Garbage storage problems
	Clutter (newspapers, toys, etc. left out)
	Dirty dishes left out
Dust mites	Stuffed toys
	Heavy rugs
	Curtains
	Upholstered furniture
	Are mattresses and pillow covers used? (Select all that apply) ____ Mattress Cover ____ Pillow Covers ____ Don’t know
Mold	Visible mold
	Wet or damp areas
	Water damage on walls, carpet, ceiling
	Evidence of leaking pipe(s)
	Working fan in bathroom? ____ Yes ____ No ____ Don’t know
Chemicals	Evidence of pesticide use
	Unvented gas oven/stove/dryer/heater
Mark the child’s bedroom with an X.
Notes:

1. Are sticky traps placed or visible near the following locations?

	Kitchen		Refrigeration		Stove
	Bathroom Sink		Other: _____________________		Other: _____________________

2. Do you observe any areas of broken plaster or peeling paint bigger than the size of a standard business letter (8.5 x 11”)?

Yes

No

Don’t Know

Notes:

3. Does the house or apartment have wall-to-wall carpet?

Yes

No

Don’t Know

Notes:

4. Does the house or apartment have evidence of cigarette smoking?

Yes

No

Don’t Know

Notes:

5. Does the house or apartment have a dog, cat, or other pet with fur?

Yes

No

Don’t Know

Notes:

6. Is the unit noisy from noise coming from inside the unit or building, so that it is difficult or distracting to hear and be heard (TV, radio, shouts of children)?

Yes

No

Don’t Know

Notes:

7. Is the unit noisy from noise coming from outside the building, so that it is difficult or distracting to hear and be heard (trains, cars, people, music)?

Yes

No

Don’t Know

Notes:

8. How would you rate the general condition of this housing unit?

1) Well-kept, good repair	2) Fair condition	3) Poor condition (peeling paint, broken windows)	4) Badly deteriorated	5) Don’t Know

9. How would you rate the general condition of this building?

1) Well-kept, good repair	2) Fair condition	3) Poor condition (peeling paint, broken windows)	4) Badly deteriorated	5) Don’t Know

10. How would you rate the general condition of most of the other buildings on this block?

1) Well-kept, good repair	2) Fair condition	3) Poor condition (peeling paint, broken windows)	4) Badly deteriorated	5) No other structures	6) Don’t Know

11. Does this building have any broken windows?

Yes

No

Don’t Know

Notes:

12. Is there trash, litter or junk within a half a block in either direction of the unit?

1) Major Accumulation	2) Minor Accumulation	3) None	4) Don’t Know

13. Is there a workable vent hood in the kitchen that ducts or vents to the outside?

    Yes

    No

    Don’t Know

    Notes:

14. Are there any open windows in the home?

Yes

No

Don’t Know

Notes: