Home Assessment Consent

Home Assessment Consent
Part of the SafeCare program is home safety. By getting rid of hazards in your home, you will lower the chance that your child will be injured. It can also help reduce allergies and asthma. The Home Accident Prevention Inventory (HAPI) helps point out hazards. The SafeCare Provider uses this checklist to see what hazards are in your home. S/he will look around areas of your home and check off if there are hazards. You may go with the SafeCare Provider while s/he does this. Most importantly, you decide where the SafeCare Provider can look. The SafeCare Provider will also measure how tall your child is to see if certain hazards are outside your child’s reach.
If you do not wish a SafeCare Provider to look in certain areas of your home, please place an "X" on the line next to that area listed below.
Living Room
Look in furniture cabinetsLook in furniture drawersLook under furnitureLook behind furnitureOther, please list below:
Bedrooms
Look in cabinetsLook in drawersLook under bedLook in closetsOther, please list below:
Bathrooms
Look in medicine cabinetsLook in cabinetsLook in drawersOther, please list below:
Kitchen
Look in cabinetsLook in drawersLook in refrigerator and freezerOther, please list below:
Miscellaneous
Look in boxesLook at personal or household productsOther, please list below:
I have read, or had read to me, the above. I agree to and understand the home safety procedure. I further understand that I can revoke this consent at any time.
Parent Signature:
Clear
Date
MonthDayYear
1
Parent Signature:
Clear
Date
MonthDayYear
2
SafeCare Provider Signature:
Clear
Date
MonthDayYear
3
Child's Reach
Child's Eye level
Should be Empty: