Inspection Form

Each board of health shall adopt and use an inspection report form available from the Department, or any other inspection report form provided it includes, at a minimum, the following: (A) Specifically labeled spaces for: (1) The name of the inspector; (2) The date and time of the inspection or investigation; (3) The location of the residence inspected; (4) The need for an additional inspection by a specialized inspector pursuant to 105 CMR 410.620(A) and the reason that such inspection is necessary; (5) A description of the conditions constituting violations; (6) A listing of the specific provisions of 105 CMR 410.000 or other applicable laws, ordinances, by-laws, rules or regulations that appear to be violated; (7) A determination by the official inspecting the premises whether the violations noted are listed in 105 CMR 410.630(A), and whether the effect of any violation(s) or conditions not listed in 105 CMR 410.630(A) may endanger or materially impair the health, safety, or well-being of any person(s) occupying the premises; and (8) The signature of the inspector preceded by the following statement: "This inspection report is signed and certified under the pains and penalties of perjury"; and (B) A copy of Occupants' Legal Rights and Responsibilities issued by the Department.