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PART III To be completed by PUBLIC HEALTH INSPECTOR
(a) Family for whom accommodation is required:-
__________ adults
__________ male children aged __________
__________ female children aged __________
(b) Present accommodation:-
Room
Living
room
Bedroom
Scullery
W.C.
Number
Floor
Whether
shared
Total persons __________ Equivalent number __________
Total number of rooms __________ Permitted number __________
Statutory Overcrowding? ____________________
(c) Standard of present accommodation:-
1. Is separate sleeping room
available for patient(s)? ____________________
2. Is there serious dampness? ____________________
3. Is water supply readily
accessible? ______________________________
4. Any other serious defects? ____________________
5. CAN POINTS BE AWARDED FOR
BAD CONDITIONS? ______________________________
(d) REMARKS:- ______________________________
Date __________ Signed __________
Public Health Inspector
RECOMMENDATION BY MEDICAL OFFICER OF HEALTH
I recommend that this application should be placed in
the following category of medical priority:-
1. IMMEDIATE __________
2. URGENT __________
3. LESS URGENT __________
4. NO RECOMMENDATION __________
Date __________ Signed __________
Medical Officer of Health