Form 50002 Assessment Questionnaire

Inspector Candidate U.S. Department of Housing OMB No. 2577-0243

Assessment Questionnaire and Urban Development (exp. xx/xx/2011)

Office of Public and Indian Housing -

Real Estate Assessment Center (PIH-REAC)

Public reporting burden for this collection of information is estimated to average 1 hour per response, including the time for reviewing instructions, searching existing data sources and copying the verifiable documentation, and completing and reviewing the collection of information. This agency may not collect this information, and you are not required to complete this form, unless it displays a currently valid OMB control number. The information collected does not lend itself to confidentiality. This information will be used by HUD to determine the basic knowledge of an inspection candidate’s inspection skills and abilities, and a determination is then made by HUD as to whether an inspection candidate has the required basic skills and abilities. The response to this information collection is voluntary.

Instructions: Please complete all sections of this questionnaire and submit the appropriate e-mail address.

Last name:	Middle name/initial:	First name:		Home phone number:	Work phone number:
Street address:			Apartment number:	Cell phone number:	Fax number:
City:				State:	Zip code:
Primary e-mail address: You will be contacted via e-mail. If this e-mail address or any of the above information changes, please notify PIH-REAC at Inspector_Assessment_Form@hud.gov.

The following questionnaire provides PIH-REAC with basic background information of your inspection skills, knowledge and abilities. You will be required to provide verifiable documentation of your answers.

Warning: False information is grounds for not certifying you or for decertifying you after you begin work. Moreover, any person who knowingly presents a false, fictitious, or fraudulent statement or claim in a matter within the jurisdiction of the U.S. Department of Housing and Urban Development is subject to criminal penalties, civil liability, and administrative sanctions.

Inspection Experience

I have completed the following number of commercial and/or residential inspections, in which I was solely responsible for conducting the inspection. During the inspection, I was required to assess the physical condition of items such as the roof, foundation, exterior walls, interior walls, electrical systems, plumbing, HVAC, doors, and windows, and provide a written report of the inspection. (This does not include termite inspections, appraisals, and site visits from property owners, managers, or real estate brokers.)

Choose only one response.

0 inspections

1 – 125 inspections

126 – 249 inspections

250 – 349 inspections

350 – 499 inspections

500+ inspections

Education

I have the following level of education.

Choose only ONE response.

I do not have a high school diploma or equivalent.

High school diploma or equivalent

Associates Degree

Bachelors Degree

Masters Degree

Specialized Training

I have completed the following number of hours of formal inspection training from a certified training academy.

Choose only ONE response.

I do not have formal inspection training from a certified training academy.

1 – 19 hours

20 – 39 hours

40 – 79 hours

80+ hours

Computer Skills

When using e-mail, which of the following activities can you perform without the assistance of another individual?

Select ALL that apply.

Never used e-mail/cannot perform any of the tasks listed below without assistance.

Send and receive messages.

Send an attached document with an e-mail.

Receive and open an attached document.

Access my e-mail on a computer other than my primary computer.

When using the Internet/World Wide Web, which of the following activities can you perform without the assistance of another individual?

Select ALL that apply.

Never used the Internet/World Wide Web/cannot perform any of the tasks below without assistance.

Access a web site.

Search using a search engine tool.

Submit information to a web site (e.g., upload a file, purchase merchandise, fill out an online survey, conduct banking, etc.).

Download files and save them to a specific location on the computer.

When it comes to using a Windows based computer, which of the following activities can you perform without the assistance of another individual?

Select ALL that apply.

Never used a Windows based computer/cannot perform any of the tasks below without assistance.

Navigate in different folders.

Open and use multiple software applications at a time.

Create, copy, move, rename, and delete files and folders.

Install new software.

I have the following experience using a computer to conduct inspections.

Choose only ONE response.

I have not used a computer to conduct an inspection.

I have conducted an inspection using an inspection report form, input the data into a computer upon completion of the inspection, and printed a final report.

I have conducted an inspection using a hand-held device while on-site and printed a final report.

I have downloaded inspection data from the Internet, conducted the inspection using a hand-held device, input observations into the inspection software while on-site, and uploaded the completed inspection to the provider.

Technical Knowledge in Residential and/or Commercial Building Trades

Please read the following list of major building trades used in residential and/or commercial construction, and mark those in which you have technical knowledge.

Select ALL that apply.

I do not have technical knowledge in any of the building trades listed below.

Carpentry

Electrical

HVAC

Masonry

Plumbing

Related Information

Please read the following narratives and mark those that describe you and your experience.

Select ALL that apply.

I am a member of a professional society of inspectors.

I have a commercial and/or residential builder’s license.

I have been the manager of a property and conducted inspections.

I have been part of the maintenance personnel of a property and conducted inspections.

I am currently a building inspector for a state or municipality.

None of the above applies.

I am willing to travel the following distance in miles to conduct a one-day inspection.

Choose only ONE response.

0 – 99 miles

100 – 199 miles

200 – 299 miles

300 – 499 miles

500+ miles

Please read the following questions carefully. It is important that you give complete and truthful answers to the questions below. If you answer yes to any of the following questions, please attach a statement to this application describing the facts and circumstances including any relevant dates that required your affirmative answer. In reviewing your application, HUD may require you to provide additional documentation in support of your application. HUD will consider the information you provide and any additional information of which the Department becomes aware related to each event you list in determining whether to approve your application. If you fail to provide the additional information requested by HUD, your application will be rejected as incomplete.

Select ALL that apply.

Yes No Have you ever been convicted of, or forfeited collateral for any felony violation? (Generally, a felony is defined as any violation of law punishable by imprisonment of longer than one year, except for violations called misdemeanors under state law that are punishable by imprisonment of two years or less. Include convictions resulting from a plea of nolo contendere (no contest). Omit: 1) any violation of law committed before your 16^th birthday; 2) any violation of law committed before your 18^th birthday, if finally decided in juvenile court or under a Youth Offender law; 3) any conviction set aside under the Federal Youth Corrections Act or similar state law; 4) any conviction whose record was expunged under federal or state law.)

Yes No Are you now under charges for any violation of law that could result in your being convicted of, or forfeiting collateral for any felony violation?

Yes No Are you required to register as a sex offender?

Yes No Are you delinquent on any federal debt? (Include delinquencies arising from federal taxes, loans, overpayment of benefits, and other debts to the United States government plus defaults on federally guaranteed or insured loans such as student or home mortgage loans.)

Yes No Are you currently suspended, debarred or otherwise excluded from participation from transactions with the Department or the Federal Government

Yes No Are you currently proposed for debarment or for any other exclusion from transactions with the Department or the Federal Government?

Certification

I certify that, to the best of my knowledge and belief, all of the information that I have provided with the submission of this Inspector Candidate Assessment Questionnaire is true, correct, complete, and made in good faith. I understand that any information I give may be verified for purposes of determining eligibility. I consent to the release of information about my ability and fitness by employers, schools, law enforcements agencies and other individuals and organizations to authorized representatives of the Federal Government.

Warning: False information is grounds for not certifying you or for decertifying you after you begin work. Moreover, any person who knowingly presents a false, fictitious, or fraudulent statement or claim in a matter within the jurisdiction of the U.S. Department of Housing and Urban Development is subject to criminal penalties, civil liability, and administrative sanctions.

___________________________________________ _________________________

TYPE Inspector candidate FULL NAME DATE

Previous editions are obsolete Page 4 of 4 form HUD-50002 (8/30/08)