Home Safety Assessment Form
General Info
Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Back
Next
Home Entry
Lightning
Rows
Adequate
Not Adequate
Driveway?
1
2
Garage?
3
4
Walkways?
5
6
At all doors?
7
8
Near the trash area
9
10
Any other areas of the yard that are used after dark
11
12
Driveway
Rows
Yes
No
Is the driveway smooth and evenly paved?
13
14
Is the slope of the driveway low enough that it does not cause a problem?
15
16
Is the transition between the driveway and surrounding surfaces (such as the yard), smooth and even, free of ruts and other things (rocks) that could cause tripping?
17
18
Walkways
Rows
Yes
No
Are walkways smooth and level (no cracks, gaps, or other tripping hazards)? Are steps along walkways clearly visible?
19
20
Do they have handrails?
21
22
Are transitions between different surfaces (a patio and sidewalk, concrete and asphalt, walkway and grass, etc.) even and level?
23
24
If there are steeply inclined walkways, do they have sturdy, easy to grasp, handrails?
25
26
Are shrubs, bushes, and grass trimmed back or removed so that they do not infringe on or obstruct the walkway (potential tripping hazard)?
27
28
Steps to the Doors
Rows
Adequate
Not Adequate
Do all steps (even single steps) have sturdy, easy to grasp (cylindrical) rails on both sides?
29
30
Are the risers on stairs and multiple steps of equal height?
31
32
Are the stair treads sturdy, level, and in good condition?
33
34
Have small single steps (that could cause tripping) been mini-ramped?
35
36
Garage
Rows
Yes
No
Are there adequate overhead lights in the garage?
37
38
Is there a clear pathway to walk through?
39
40
Do entry stairs or ramps to the house have railings?
41
42
Additional Notes
Back
Next
Home (Inside)
Entry Ways and Vestibules
Rows
Yes
No
Have throw rugs been removed?
43
44
Is there a clear pathway through the entry hall?
45
46
Are all cords and wires out of the pathway?
47
48
Are thresholds low enough so someone does not trip over them?
49
50
Is there adequate lighting?
51
52
Is the light switch at the entrance to the room?
53
54
Hallways
Rows
Yes
No
If people need support, are there handrails along the hall?
55
56
Are halls free of clutter and other tripping obstacles?
57
58
Are carpet runners tacked down or have anti-skid backing?
59
60
Are thresholds less than one inch so they are not tripping hazards?
61
62
Is there adequate lighting?
63
64
Is there a light switch at the ends of the hall?
65
66
Bathroom
Rows
Yes
No
Is there a light switch at the entry?
67
68
Is there adequate lighting overall?
69
70
Is there a nightlight?
71
72
Is the door threshold less than one inch?
73
74
Is the room free of clutter and tripping hazards?
75
76
Is the flooring non-slip/non-skid (including throw rugs)?
77
78
Are there grab bars in other areas of the room as needed?
79
80
Is the room kept warm during bathing (heat lamp, towel warmers, etc.)?
81
82
Kitchen
Rows
Yes
No
Are frequently used items visible and easily reached (front of pantry and refrigerator)?
83
84
Are sink faucets easy to reach and read?
85
86
Is it easy to determine where the hot and cold areas of the faucet are?
87
88
Is it easy to mix the temperature?
89
90
Are burners and control knobs clearly labeled and easy to use?
91
92
Are the controls on the front of the stove, not the back?
93
94
Is there a close resting place nearby for hot vessels coming out of the oven?
95
96
Is glass cookware being used so person sees food is being cooked?
97
98
Is the microwave easy to read, reach, and operate?
99
100
Laundry Room
Rows
Yes
No
Is there a light switch at the entry?
101
102
Is there sufficient lighting?
103
104
Is the route to the laundry room (stairs) safe?
105
106
Are the appliances at the right height so it easy to get clothes in/out of the washer and dryer?
107
108
Are the control knobs easy to reach, read, and operate?
109
110
Are laundry supplies easy and safe to reach?
111
112
Is there a non-slip floor surface?
113
114
Are tripping hazards off the floor (laundry basket or dirty clothes)?
115
116
General Home Safety Concerns
Rows
Yes
No
Can an older person contact someone in an emergency (medi-alert, names and numbers by phone, picture telephone, etc.)?
117
118
Are smoke detectors and carbon monoxide alarms installed and working?
119
120
Is there a fire extinguisher in the house?
121
122
Is there a safe place outside to hide a key to the house for emergency entry?
123
124
Additional Notes
Submit
Should be Empty: