Bed Bug Inspection Checklist
Date
*
-
Month
-
Day
Year
Date
Inspected by
*
First Name
Last Name
Location
*
Home Name
Manager at that location
*
Chanelle Copeland
Chasidy Roach
Cheryl Eversole
Cynthia Best
Ida Seckler
Jean Cox
Jon Hegal
Joy Barnes
Other
Email
example@example.com
Bedrooms #1-5 Y=Visible Signs of Infestation N=No Visible Signs of Infestation
*
Rows
#1 Y
#1 N
#2 Y
#2 N
#3 Y
#3 N
#4 Y
#4 N
#5 Y
#5 N
Trim around top and bottom of mattress - even if encased
Wrap on bottom of box spring
Dresser drawer (at least one): inside & out--top & bottom
Bed frame - all parts
Night stand - back, top and bottom
Headboard - front, back and edges
Bedding, including sheets, blanket and pillow
Windows - covering, sashes and sills
Door frames and floor threshold
Electrical outlet covers - edges
In baseboards near bed - if other signs pull back carpet
Living Area
*
Rows
Y
N
Upholstered furniture: seams, tufts, skirts and crevices
Tables - joints, legs and underneath
Baseboard near furniture - pull back carpet
Electrical outlet covers - edges
Carpeting around furniture
Dining Area
*
Rows
Y
N
Chairs - joints, legs and undeneath
Table - joints, legs and underneath
Baseboards near furniture - pull back carpet
Electrical outlet covers - edges
Submit to Your DM
Office Code
Choose
There are visible signs of infestation in one or more areas.
There are no visible signs of infestation.
Reported to
*
County Board SSA(s) for non-licensed site only
Landlord for non-licensed sites only
Siffrin Property Maintenance notified for licensed sites only
Date Notified
*
-
Month
-
Day
Year
MM-DD-YYYY
Signature of Home Coordinator
*
Submit to Siffrin
Should be Empty: