Home Safety Assessment

Home Safety Assessment
Student: ____________________
Date:_______________________

Assigned Agency:______________

Safety Hazard Yes No

Are medications safely stored and adequately labeled? ___ ___
Are throw rugs, area rugs, and flooring materials secured? ___ ___
Is there adequate lighting in each room? ___ ___
Are there telephone cords or electrical cords in walkways? ___ ___
Do the entry doors locks with deadbolts? ___ ___
Are combustibles, such as newspapers, stored ___ ___
at least three feet from stove, fireplace or heater?

Is there adequate space around space heaters? ___ ___
Are there exposed heating pipes? ___ ___
Is the room/house heated cooled adequately and safely? ___ ___
Is water heater set at 120F or lower?
Is there a portable fire extinguisher available in the kitchen? ___ ___
Do occupants who are smokers demonstrate safe handling
of cigarettes, lighters and matches? ___ ___

Does the gas at the stove, furnace , and space heater work properly? ___ ___
Are walkways clear, sturdy and wide enough to walk safely (using assistive devices
if necessary)? ___ ___

If burglar bars are present on doors and/or windows, will they bend for
Emergency exit or is the key close by? ___ ___

Is there a phone within easy reach? ___ ___
Is there a working smoke detector near the kitchen and near each sleeping area? ___ ___
Dos the bathtub have a non-skid surface? ___ ___
If oxygen is in use in the hours, are all occupants aware of oxygen and cord safety? ___ ___
Are all occupants able to safely exit the home in five minutes or less? ___ ___
Are guns or weapons safely stored? ___ ___
Are there secure handrails on stairs? ___ ___
If a ramp is needed, is one present and safely constructed? ___ ___

Sanitation Hazards
Is there indoor running water? ___ ___
Is food stored properly? ___ ___
Are there indoor toilet facilities? ___ ___
Do the stove and/or microwave operate properly? ___ ___
Is trash picked up on a regular scheduled basis? ___ ___
Is the water in the kitchen, bathroom and utility are working properly
each room? ___ ___

Are there signs of rodent or pest infestation? ___ ___
Is there adequate refrigeration? ___ ___
Comments:

Modifications recommended after your assessment_____________________________________________________________

What surprised you when doing your home safety assessment?

Why are home safety assessments important for a public health nurse to know and do?

What kind of teaching/topics can you see would be important for a public health nurse to do as a result of a home safety assessment?