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HOSTS for HOSPITALS : Private-Setting Lodging Intake

Property Owner *

Corporation

Individual

Corporation Name

Individual Name

Contact Name *

Office Number *

Cell *

Email *

How learned about HfH *

Unit: Address Line 1 *

Unit: Address Line 2

City *

State *

Zip Code *

Unit Number

The Unit

Easy to find *

Yes

No

Comments

Inviting *

Yes

No

Comments

In good repair *

Yes

No

Comments

Clean *

Yes

No

Comments

Fire extinguisher *

Yes

No

Comments

Smoke alarms *

Yes

No

Comments

Easily accessible to public transportation *

Yes

No

Comments

Access to parking *

Yes

No

Comments

Welcomes guests who smoke *

Yes

No

Comments

Speaks foreign languages *

Yes

No

Comments

Wireless computer access *

Yes

No

Comments

Computer available for guest *

Yes

No

Comments

TV (provide where & if cable) *

Yes

No

Comments

Kitchen (provide if stove, fridge, etc.) *

Yes

No

Comments

Steps into unit (provide number) *

Yes

No

Number of Steps *

Affiliations:

Other Comments:

How many rooms? *

1st Room

Floor Level *

Room Name

Number of steps

Rail

Yes

No

Clean *

Yes

No

Comments

Inviting *

Yes

No

Comments

Privacy: door closes firmly *

Yes

No

Comments

Privacy: Window coverings *

Yes

No

Comments

Closet Space *

Yes

No

Comments

Drawer Space *

Yes

No

Comments

Well-lit *

Yes

No

Comments

Heated *

Yes

No

Comments

Air-Conditioned *

Yes

No

Comments

Fan *

Yes

No

Comments

Bath *

Yes

No

Comments

Shower *

Yes

No

Comments

Bathroom: Private *

Yes

No

Comments

Bathroom: Attached *

Yes

No

Comments

Bathroom: Shared With

Bathroom: Location *

Bed Type

2nd Room

Floor Level *

Room Name

Number of steps

Rail

Yes

No

Clean *

Yes

No

Comments

Inviting *

Yes

No

Comments

Privacy: door closes firmly *

Yes

No

Comments

Privacy: Window coverings *

Yes

No

Comments

Closet Space *

Yes

No

Comments

Drawer Space *

Yes

No

Comments

Well-lit *

Yes

No

Comments

Heated *

Yes

No

Comments

Air-Conditioned *

Yes

No

Comments

Fan *

Yes

No

Comments

Bath *

Yes

No

Comments

Shower *

Yes

No

Comments

Bathroom: Private *

Yes

No

Comments

Bathroom: Attached *

Yes

No

Comments

Bathroom: Shared With

Bathroom: Location *

Bed Type

3rd Room

Floor Level *

Room Name

Number of steps

Rail

Yes

No

Clean *

Yes

No

Comments

Inviting *

Yes

No

Comments

Privacy: door closes firmly *

Yes

No

Comments

Privacy: Window coverings *

Yes

No

Comments

Closet Space *

Yes

No

Comments

Drawer Space *

Yes

No

Comments

Well-lit *

Yes

No

Comments

Heated *

Yes

No

Comments

Air-Conditioned *

Yes

No

Comments

Fan *

Yes

No

Comments

Bath *

Yes

No

Comments

Shower *

Yes

No

Comments

Bathroom: Private *

Yes

No

Comments

Bathroom: Attached *

Yes

No

Comments

Bathroom: Shared With

Bathroom: Location *

Bed Type

4th Room

Floor Level *

Room Name

Number of steps

Rail

Yes

No

Clean *

Yes

No

Comments

Inviting *

Yes

No

Comments

Privacy: door closes firmly *

Yes

No

Comments

Privacy: Window coverings *

Yes

No

Comments

Closet Space *

Yes

No

Comments

Drawer Space *

Yes

No

Comments

Well-lit *

Yes

No

Comments

Heated *

Yes

No

Comments

Air-Conditioned *

Yes

No

Comments

Fan *

Yes

No

Comments

Bath *

Yes

No

Comments

Shower *

Yes

No

Comments

Bathroom: Private *

Yes

No

Comments

Bathroom: Attached *

Yes

No

Comments

Bathroom: Shared With

Bathroom: Location *

Bed Type

5th Room

Floor Level *

Room Name

Number of steps

Rail

Yes

No

Clean *

Yes

No

Comments

Inviting *

Yes

No

Comments

Privacy: door closes firmly *

Yes

No

Comments

Privacy: Window coverings *

Yes

No

Comments

Closet Space *

Yes

No

Comments

Drawer Space *

Yes

No

Comments

Well-lit *

Yes

No

Comments

Heated *

Yes

No

Comments

Air-Conditioned *

Yes

No

Comments

Fan *

Yes

No

Comments

Bath *

Yes

No

Comments

Shower *

Yes

No

Comments

Bathroom: Private *

Yes

No

Comments

Bathroom: Attached *

Yes

No

Comments

Bathroom: Shared With

Bathroom: Location *

Bed Type

6th Room

Floor Level *

Room Name

Number of steps

Rail

Yes

No

Clean *

Yes

No

Comments

Inviting *

Yes

No

Comments

Privacy: door closes firmly *

Yes

No

Comments

Privacy: Window coverings *

Yes

No

Comments

Closet Space *

Yes

No

Comments

Drawer Space *

Yes

No

Comments

Well-lit *

Yes

No

Comments

Heated *

Yes

No

Comments

Air-Conditioned *

Yes

No

Comments

Fan *

Yes

No

Comments

Bath *

Yes

No

Comments

Shower *

Yes

No

Comments

Bathroom: Private *

Yes

No

Comments

Bathroom: Attached *

Yes

No

Comments

Bathroom: Shared With

Bathroom: Location *

Bed Type