Social Worker Home Visit Checklist
Date & Time of Visit
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Social Worker Name
First Name
Last Name
Case Name
Case Manager (If Applicable)
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
People Present in Home During the Visit
Case Type
Family Centered Services
Family Centered Out-of-Home
Other
Safety Issues
Rows
Yes
No
Is the property in a high crime or high risk area?
1
2
Are there any indications for potential violence (cited in person’s history or other members of the household)?
3
4
Does anyone in the household have access to weapons?
5
6
Is there any risk of harm?
7
8
Is there a risk of infection due to an unclean environment?
9
10
Are there any cultural issues staff need to be aware of?
11
12
Are smokers present in the environment?
13
14
Additional Notes
Next Visit Date & Time
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Signature
Signed Date
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
Should be Empty: