Healthcare Roof Assessment

HEALTHCARE ROOF ASSESSMENT

Assessment ID:     Assessment Date:

Assessor Information

Patient / Resident Information

Patient Name:     DOB:

Insurance Information

Medical History Relevant to Environmental Risk

Chronic respiratory condition: Asthma COPD Other

Mobility limitations: Yes No    If yes, describe:

Roof Assessment — Observations

Asphalt shingle Metal Flat / built-up Tile Other

Missing shingles Cracked tiles Corrosion / rust Other

Active leak observed: Yes No    If yes, interior locations:

Safety Hazards and Access

Roof access safe for inspection: Yes No

Assessment Findings, Recommendations and Urgency

Urgency Level: Immediate (within 24 hours) Short-term (within 7 days) Routine (monitor/plan)

Authorizations, Notices and Certifications

Consent to Inspect and Disclose: The undersigned authorizes the assessor and affiliated personnel to access the roof and related building spaces for the purpose of conducting this assessment. The undersigned consents to disclosure of assessment findings to contractors, environmental remediation professionals, and the patient’s health care team as necessary to address identified hazards. This authorization is limited to information reasonably necessary to facilitate repairs, remediation, or health care interventions.

Limitation of Liability: The assessor will exercise reasonable professional care in conducting visual inspection. This assessment is not a comprehensive structural or engineering inspection and does not substitute for detailed structural, roofing, or environmental testing. Recommendations provided are professional observations; the assessor is not responsible for costs or outcomes of repairs performed by third-party contractors.

Right to Withdraw: The patient or authorized representative may withdraw consent for further access at any time by notifying the assessor in writing. Withdrawal of consent does not negate the validity of observations documented prior to withdrawal.

Privacy Acknowledgment: I acknowledge that assessment records may contain protected health information. I have received a privacy notice and authorize the limited use and disclosure of health-related information for purposes of assessment, remediation coordination, and continuity of care as described above.

I consent to the inspection, disclosure, and recommendations described in this Healthcare Roof Assessment.

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