Title Page

  • Site conducted

  • Document No.

  • Resident Name

  • Full Address

  • Conducted on

  • Prepared by

  • Review Date

Hazard and risk factors - Smoking

    Cicumstances
  • Smoking concerns

  • Evidence

  • Existing control measures

  • Outstanding risk

  • Additional actions required

  • No further action required

Hazard and risk factors - Cooking

    Circumstances
  • Cooking concerns

  • Evidence

  • Existing control measures

  • Outstanding risk

  • Additional control measures

  • No further action required

Hazard and risk factors - Electrical

    Circumstances
  • Electrical concerns

  • Evidence

  • Existing control measures

  • Outstanding risk

  • Additional control measures

  • No further action required

Hazard and risk factors - Portable heaters

    Circumstances
  • Portable heater concerns

  • Evidence

  • Existing control measures

  • Outstanding risk

  • Additional control measures

  • No further action required

Hazard and risk factors - Candles

    Circumstances
  • Candle concerns

  • Evidence

  • Existing control measures

  • Outstanding risk

  • Additional control measures

  • No further action required

Hazard and risk factors - Deliberate ignition

    Circumstances
  • Ignition concerns

  • Evidence

  • Existing control measures

  • Outstanding risk

  • Additional control measures

  • No further action required

Hazard and risk factors - Alcohol or drug use

    Circumstances
  • Alcohol/drug use concerns

  • Evidence

  • Existing control measures

  • Outstanding risk

  • Additional control measures

  • No further action required

Hazard and risk factors - Hoarding (access)

    Circumstances
  • Hoarding concerns

  • Evidence

  • Existing control measures

  • Outstanding risk

  • Additional control measures

  • No further action required

Hazard and risk factors - Oxygen

    Circumstances
  • Oxygen concerns

  • Evidence

  • Existing control measures

  • Outstanding risk

  • Additional control measures

  • No further action required

Hazard and risk factors - Sensory impairment

    Circumstances
  • Impairment concerns

  • Evidence - extent of impairment

  • Existing control measures

  • Outstanding risk

  • Additional control measures

  • No further action required

Hazard and risk factors - Capacity to respond to fire alarm

    Circumstances
  • Capacity concerns

  • Evidence

  • Existing control measures

  • Outstanding risk

  • Additional control measures

  • No further action required

Hazard and risk factors - Ability to evacuate

    Circumstances
  • Evacuation concerns

  • Evidence

  • Existing control measures

  • Outstanding risk

  • Additional control measures

  • No further action required

Hazard and risk factors - Other factors

    Circumstances
  • Other concerns

  • Details

  • No further action required

Risk Level

  • Grade

  • Have all existing and additional controls measures been explored and introduced before recording this level?

Media

Photographic evidence

    Permission
  • Does the tenant agree to photographs being taken?

  • Tenant name and signature

  • Smoking

  • Cooking

  • Electrical

  • Portable heater

  • Candles

  • Hoarding

  • Oxygen

  • Other

Assessor(s) details

  • Name & Job Title

  • Name & Job Title

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.