* Required Information
Bathroom Safety
Is there safety equipment in the bathroom?
Yes
No
N/A
Follow Up Needed
Is the toilet height appropriate?
Yes
No
N/A
Follow Up Needed
Is the Shower/Tub usable and safe?
Yes
No
N/A
Follow Up Needed
Electrical
Are there old, cracked or exposed wires?
Yes
No
N/A
Follow Up Needed
Are there visible frayed electrical cords in the home?
Yes
No
N/A
Follow Up Needed
Is the visible circuit overload?
Yes
No
N/A
Follow Up Needed
Fire
Is there smoke detector in the home?
Yes
No
N/A
Follow Up Needed
Is oxygen being used near an open flame?
Yes
No
N/A
Follow Up Needed
Is there a fire extinguisher?
Yes
No
N/A
Follow Up Needed
Is cigarette smoking happening in the home?
Yes
No
N/A
Follow Up Needed
Is the house free of gas odors?
Yes
No
N/A
Follow Up Needed
Is there a fire escape plan or route?
Yes
No
N/A
Follow Up Needed
Structural Barriers
Is there a pool?
Yes
No
N/A
Follow Up Needed
Is the pool gated, and supervised with minors?
Yes
No
N/A
Follow Up Needed
Any loose carpeting, cord etc. posing a threat?
Yes
No
N/A
Follow Up Needed
Does the phone/heating/ventilation work?
Yes
No
N/A
Follow Up Needed
Is there hot/cold running water?
Yes
No
N/A
Follow Up Needed
Is the furniture placed safely?
Yes
No
N/A
Follow Up Needed
Other
Are the animals appropriate with home setting?
Yes
No
N/A
Follow Up Needed
Family understands universal precautions
Yes
No
N/A
Follow Up Needed
Medications stored correctly?
Yes
No
N/A
Follow Up Needed
Earthquake Prepared with Food/Meds and Supply’s
Yes
No
N/A
Follow Up Needed
Home is appropriate for care
No follow-up action/intervention indicated at this time
Plan of Action: Client/Family/PCG was instructed in
Client Name
*
Assessed by
*
Date