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Home Safety Checklist
Step
1
of
5
20%
General Information
Participant Name
Address
Date of assessment
Note
Safety Criteria
Entrance to Home
Are there outside lights covering the sidewalks and/or other entranceways?
Yes
No
Are the steps & sidewalks in good repair and free from debris/material?
Yes
No
Is a ramp needed?
Yes
No
Are the railings on the steps secured?
Yes
No
Is there a functional peephole in the front door?
Yes
No
Does the door have a deadbolt lock that does not require a key to open it from the inside (unless the client tends to wander)?
Yes
No
General
Is there an emergency plan in place?
Yes
No
Are working smoke detectors installed?
Yes
No
Is there a “ready-to-use” fire extinguisher(s) on the premises?
Yes
No
Are inside halls and stairways free of clutter/debris?
Yes
No
Are throw rugs removed?
Yes
No
Are there sturdy handrails or banisters by all steps and stairs?
Yes
No
Are electrical cords non-frayed and placed in a manner to avoid tripping?
Yes
No
Are electric outlets/switches overloaded (e.g. warm to the touch)?
Yes
No
Are rugs secured around the edges?
Yes
No
Are hazardous products labelled and kept in a secure place?
Yes
No
Is there a need for a stool to reach high shelves/cupboards?
Yes
No
Is smoking paraphernalia handled safely (e.g. cigarettes put out)?
Yes
No
Does anybody smoke in homes where oxygen is in use?
Yes
No
Are all animals/pets, on-site, controlled?
Yes
No
Is the home free from bugs, mice and/or animal waste?
Yes
No
Are materials stored safely and at a proper height?
Yes
No
Does the client wear an emergency response necklace/bracelet?
Yes
No
Are the polished floors waxed or waxed-free?
Yes
No
Are there any weapons on the premises?
Yes
No
Medications
Are all medications marked clearly?
Yes
No
Are medications named?
Yes
No
Are medications dated?
Yes
No
Are instructions given as to how medications are to be taken?
Yes
No
Are instructions given as to when medications are to be taken?
Yes
No
Medical Equipment | Supplies
Are used needles placed in a sharp container?
Yes
No
Is oxygen tubing kept off the walking path?
Yes
No
Is medical equipment properly stored?
Yes
No
Living Areas
Are doorways wide enough to carry loads through and get a wheelchair/walker through?
Yes
No
Are light switches accessible so they can be turned on/off without walking across a dark room?
Yes
No
Are sofas & chairs high and firm enough for easy sitting and rising?
Yes
No
Is there a telephone in the room that is easily accessible from the bed?
Yes
No
Is list of emergency telephone numbers by the telephone?
Yes
No
Do telephone cords/electronic wires run across walking areas?
Yes
No
Are there castors or wheels on furniture?
Yes
No
Does sitting furniture have armrests which are strong enough for getting in and out?
Yes
No
Are phone & extension cords out of the foot traffic area?
Yes
No
Is the room clutter-free?
Yes
No
Are heaters at least 12 inches from furniture and drapes?
Yes
No
Bathroom
Are there glass doors on the bathtub/shower?
Yes
No
Is there a non-skid surface/mat in the bathtub/shower?
Yes
No
Are there grab-bars on the bathtub/shower and adjacent to the toilet?
Yes
No
Is there a raised toilet seat (if client has trouble getting on/off toilet)?
Yes
No
Is a hand-held shower spray required?
Yes
No
Is the water temperature below scalding (e.g. below 120?
Yes
No
Is there a shower bench/bath seat with a hand-held shower wand available?
Yes
No
Does the bathroom have a night light?
Yes
No
Are there unsafe loose rugs, carpet or tiles on floor?
Yes
No
Bedroom
Are there any scatter rugs?
Yes
No
Is the bed lower than “back-of-the-knee” height?
Yes
No
Is there a chair with armrests & firm seat (to reduce falls while dressing)?
Yes
No
Does furniture have castors or roll?
Yes
No
Is there a telephone in the room that is easily accessible from the bed?
Yes
No
Is list of emergency telephone numbers by the telephone?
Yes
No
Is there a flashlight, light switch or lamp beside the bed?
Yes
No
Is there a night light?
Yes
No
Kitchen
Is the floor waxed or in a slippery condition?
Yes
No
Do the “ON” buttons work on all appliances?
Yes
No
Are there any flammable items near the heat source?
Yes
No
Are stove controls accessible and easy to use?
Yes
No
Are items used the most stored between eye and knee level?
Yes
No
Is there an uncluttered workspace near the cooking area (to avoid having to carry items)?
Yes
No
Are dishcloths, dishtowels & oven mitts away from stove burners/flames?
Yes
No
Lighting
Is there adequate lighting in all stairways and hallways?
Yes
No
Is there a light switch at both the top and bottom of the stairs?
Yes
No
Is there a night light between the bedroom and bathroom?
Yes
No
Client's/Resident's Potential for Violence
Is there a history of violence?
Yes
No
Are there violent fantasies or plans of violence?
Yes
No
Is there a level of support from a significant other?
Yes
No
Are there signs & symptoms?
staring and eye contact
tone & volume of voice
pacing
anxiety
mumbling
Select All
Neighborhood Hazards
Is there sufficient lighting?
Yes
No
Can individuals be heard if they call for help?
Yes
No
Are there people nearby who can help?
Yes
No
Are there improvements that can be made to enhance safety?
Yes
No
Other
This assessment is completed by
Name/Position
Signature
Date
Name/Position
Signature
Date
Participant/Rep/Guardian Acknowledgment
Name
Signature
Date
Name
Signature
Date
Staff Acknowledgment
Name
Signature
Review date of this document
Supervisor/Manager sign off
Name
Signature
Review date of this document
Supervisor/Manager sign off