Pillar Homecare LLC
Pest Control Inspection Form
Date of Drill
-
Month
-
Day
Year
Date
Time of Rounds
Drill Type
Monthly
Quarterly
Client Name
*
First Name
Last Name
Client Address/Location of Pest Control Rounds
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Pest Noted on Rounds
*
Please Select
Yes
No
No visible pest but signs of concern noted
Name of Caregiver on Duty During Rounds
Has Caregiver Observed Pests in Home?
*
Yes
No
Pest Control Treatment Options Implemented - select all that apply
Applied Treatment to Area(s)
Installed pest detection devices
Referred to Pest Control Company
Clean/declutter
Other * please detail in comments below
Please specify special service instructions
Additional Notes
Client or Responsible Party Signature
*
Caregiver Signature
*
Signature of Pillar Homecare Staff Conducting Rounds
Submit
Should be Empty: