Home Visit Safety Checklist

Home Visit Safety Checklist
Please complete this checklist to assess and document safety conditions during your home visit.
Assessor Full Name
First NameLast Name
Assessor Email Address
example@example.com
Assessor Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Date of Visit
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Home Address
Street Address
Street Address Line 2
CityState / ProvincePostal / Zip Code
Resident's Name (if applicable)

Safety Checklist

Rows	Yes	No	N/A
Are smoke detectors present and working?
Are carbon monoxide detectors present and working?
Are fire extinguishers accessible and functional?
Are emergency exits clear and accessible?
Are walkways and stairs free of tripping hazards?
Are electrical outlets and cords in safe condition?
Are medications stored safely and out of reach of children?
Is there adequate lighting in all areas?
Are bathroom safety features (e.g., grab bars, non-slip mats) present?
Are hazardous materials (cleaners, chemicals) stored securely?

Are there any additional safety concerns or hazards observed? Please describe.
Recommendations for improving safety (if any)
Do you confirm that you have completed this safety checklist to the best of your ability?
Signature of Assessor
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