Elderly Home Security Assessment Form
Evaluate the safety and security conditions of an elderly resident's home. Please answer each section to help identify potential improvements.
Resident's Name
*
First Name
Last Name
Primary Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
What is the current living situation?
*
Lives alone
Lives with family
Has a caregiver
Other
How secure are the main entrances and locks?
*
1
2
3
4
5
Which of the following are present at entry points? (Select all that apply)
*
Deadbolt locks
Peephole or camera
Security alarm
None of the above
Is there sufficient lighting at entrances and walkways?
*
Yes, well-lit
Some areas need improvement
Poorly lit
Trip and Fall Hazards Assessment
*
Rows
None
Some
Many
Loose rugs
1
2
3
Cluttered walkways
4
5
6
Uneven flooring
7
8
9
How prepared is the home for emergencies (e.g., fire, medical, power outage)?
*
Not prepared
1
2
3
4
Very prepared
5
1 is Not prepared, 5 is Very prepared
Which fire safety devices are present? (Select all that apply)
*
Smoke detectors
Fire extinguisher
Carbon monoxide detector
None of the above
Please describe any additional security concerns or suggestions.
Submit Assessment
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