Elimination Communication Safety Assessment Form
Assess your environment and practices to ensure safety during elimination communication. Please answer the following questions to help evaluate readiness and identify any areas for improvement.
How familiar are you with elimination communication safety guidelines?
*
Not familiar
1
2
3
4
Very familiar
5
1 is Not familiar, 5 is Very familiar
Is the elimination area free from hazards (e.g., sharp objects, choking hazards, slip risks)?
*
Yes
No
Not sure
How confident are you in supervising your child throughout the elimination communication process?
*
1
2
3
4
5
Please rate the following aspects of your environment:
*
Rows
Safe flooring
Accessible supplies
Good lighting
Poor
1
2
3
Fair
4
5
6
Good
7
8
9
Excellent
10
11
12
Have you prepared a plan for emergencies (e.g., slips, spills, unexpected accidents)?
*
Yes
No
How often do you check and clean the elimination area?
*
Please Select
After every use
Once daily
A few times per week
Rarely
Do you have all necessary supplies within easy reach (e.g., wipes, clean clothes, potty)?
*
Yes
No
Partially
How would you describe your child’s readiness for elimination communication?
*
Very ready
Somewhat ready
Not ready
Not sure
Please share any specific safety concerns or comments (optional):
Submit Assessment
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