Client Name:


Environment Surrounding Client Home:

In what type of structure or residence does client reside?

If apartment how many floors:


How does one enter or exit home? (Describe security, alarm systems, locking devices, etc.)

Is there adequate exit/entrance lighting?

Signs of Vandalism?


General Employee Safety
Describe clients overall health:

How many medications does client take daily?

How are medications tracked?
Are there medications in the home that are no longer taken?
Does client wear a hearing aid?

How many individuals live in the home? (#) What are their relation to client?

Are there any pets in the home?

# of Cats_________________ # of Dogs_________________- Other__________________

Any History of biting or Scratching?

Excessive barking?

Any history of Jumping on Guests? If yes is there any place to contain pet during employee visits?

Proof of vaccinations last two years?

Excessive pet hair build up?

Has the client, or anyone else who may be residing and/or expected to visit, have any; Criminal History: Name Psychological disorders: Name Violent/combative behavior: Name

Have these issues been addressed in the care plan? Explain:

Are there visible signs of, or behaviors of excesive alcohol and/or prescription pain killers or other mood-altering medications present with this client?

Expalin above issues:

Any history or evidence of abuse?

Are there firearms present in the clients residence?

How are they secured?

Any evidence of mold or fungus?

Is food properly stored in a sanitary manner?

Food and non-food items stored in the same cabinet/closet?

Spoiled food or beverage in the home?

Signs of roaches, rodent or varmint infestations?

Any signs of bed bugs?

Any cleaning products and/or other potential poisons that are not labeled or stored in original containers?

Excessively loud noise inside or outside of home?

Doors equipped with proper locking mechanisms?

Identify potential security issues or personal safety concerns:

Fire/ Life Safety

Are there any space heaters in use?

Are heaters, including wood burning stovves or gas fireplaces, equipped with screens or barriers to prevent contact with open flames or hot surfaces?

If no, describe concerns and possible solutions:

Are combustible items stored away from any stove, heater, or fireplace in the home?

If no, describe concerns and possible solutions?

Are appliances properly ventilated to homes exterior?

Any examples of overloaded electrical ciruits or outlets, etc.

Any damaged electrical cords?

Any evidence of candle use?

Excessive trash build up, clutter or signs of hoarding?

Unsafe smoking materials?

Curtains and towels stored at least 12 inches from heat sources, kitchen burners and other potential ignition sources?

Home equipped with appropriate number of working smoke detectors?

Smoke detectors tested periodically?

Is home equipped with a carbon monoxide detector?

Working fire exinguisher available?

Indicate location of fire extinguisher?

Is there an updated emergency contacts list?

If oxygen is used in the home, is it properly stored?

Are working flashlights readily available?

Is there ready access to a telephone?

Is there an emergency exit plan?

When was the last furnace inspection: (Enter date)

Slip,Trip and Fall Safety

Is lighting adequate inside and outside of the home?

If no, describe concerns and possible solutions?

Are exterior walkways in good condition (no uneven or broken sections).

Are steps to client residence in good condition and free of tripping hazards?

Do exterior steps have appropriate handrails?

Are there arrangements for snow and ice removal from sidewalks and ice salt/sanding prior to staff arrival?

Are floor rugs used at entrances, bathrooms, bedrooms or kitchen?

Describe any concerns with rugs?

Clear pathways are present into the home and from room to room?

Are floor surfaces in living areas in good condition to prevent trips and falls?

Carpets well fastened, no frayed sections?

Is furniture positioned to provide clear traffic areas?

Has furniture with wheels been eliminated or equipped with wheel locking devices?

Any awkwardly placed furniture?

Identify any hinderances to providing client assistance:

Do all stairways have securely affixed handrails on both sides?

Do handrails extend beyond lentgh of steps?

Are stairways free of clutter and storage?

Are there light switches at top and bottom of stariways?

Night lighting available and installed?

Extension cords used?

Describe efforts to eliminate trip hazards from cords?

Can items in closets and cupboards be reached without using a step stool?

Are stove knobs all installed and easily reachable?

Non-slip mats installed in bathing areas?

Blood-borne Pathogens/Personal Protective EquipmentSafet

Are there any exposures to: Infectious diseases, biological or chemicals that will impact employee safety?

Review care plan and record appropriate employee training and PPE needs:

Any sharps exposures?

Appropriate sharps containers and handling in place?

Safe Patient Handling/Ergonomics

Is client ambulatory?

Based on current client assessment (weight/mobility/special needs) what mobility issues are present? Decribed assistive devices and equipment needs?

Client family willing to utilize appropriate lifting devices?

Are restrooms appropriately sized and not too restrictive?

Grab bars installed in restrooms?

Heavy objects stored on lower shelves?

Check Equipment needed?

Gait Belt

Sit-to-stand lift?

Total Lift device?

Adjustable bed?

Grab bars in shower and bathroom.

Rasing seat commode?

Bathing chair/stool?

Portable toilet?

Wheel chair?


Repositioning sheets?

Bariatric equipment: bed, commode, walker, etc.

Slide board?

Pivot disk?

Other equipment necessary or comments:

Wandering or Exit seeking Behaviors

Does client exhibit disorientation regarding self, time, location, etc.

Describe family concerns in this area:

Does client wander or seek to exit home?

Describe control measures:

Have there been any reports of client being formally missing and a search conducted?

If yes, describe event and actions taken. Is this addressed in care plan?

Vehicle Safety

Is employee expected to transport client or run errands?

Will transport be done using clients vehicle?

Is vehicle insurance current?

Is employee familiar with this type of vehicle?

Are appropriate assist devices/equipment available?

Does employee have valid drivers license and up to date insurance card?

Will client need assistance entering/exiting vehicle?

Has vehicle been serviced appropriately and inspected? (Brakes, signals, lights, tires, etc.)

Discuss any requirements or issues related to client transportation:

Other-Special Circumstances

Enter comments/concerns or other pertinent information:

Completed by:
Please note that this checklist is a hypothetical example and provides basic information only. It is not intended to take the place of, among other things, workplace, health and safety advice; medical advice, diagnosis, or treatment; or other applicable laws. You should also seek your own professional advice to determine if the use of such checklist is permissible in your workplace or jurisdiction.