Patient Details

CHIS number


Street name and number


Post Code

1.0 - Previous Alerts / Flags

1.1 - Is there a known alert placed on the property, individual or other inhabitants of the property?

Detail the nature of the alert and the source

2.0 - Communication from site

2.1 Does the site have NO mobile phone coverage (Optus)?
Yes = the site has no / limited mobile phone coverage

2.2 Does the site have NO landline which is connected and operational?
Yes = the site has NO 'phone

3.0 - Pets and animals

3.1 - Are there any dogs or pets that may present a risk to staff members?

Detail the animal and safety concerns

3.2 - Are there NO means of controlling the animal(s) if required during the duration of the visit?

4.0 - Parking

4.1 - Street parking is NOT available

4.2 - Parking is NOT secure?

5.0 - Access

5.1 - There is reduced access to the property

Provide Details

5.2 - Entry and walkways DO NOT provide safe access

Provide Details

5.3 - Entry and Walkways DO NOT allow safe transportation of equipment

Provide Details

6.0 - Premises

6.1 - Site is NOT powered

6.2 - Structural condition of premises

Provide Details

6.3 - Hygiene

Provide Details

6.4 - Infestation

Provide Details

6.5 - Squalor

Provide Details

6.6 - Hoarding

Provide Details

7.0 - Appliances

7.1 - Gas

Is there NO safety switch

8.0 - Medical Alerts

8.2 - Allergies

Provide details including management plan

8.3 - Multi Resistant Organism(s)

Provide details including type of MRO(s) and management plan(s)

8.4 - Adverse drug reactions()

Provide details including drug name, reaction and management plan

8.5 - Serious medical condition(s)

Detail condition(s) and any management plans

8.6 - Drug seeking behaviours

Provide details

9.0 - Consent

9.1 - Level of consent provided

Provide details including any special conditions

10.0 - Other

Firearms / weapons

10.1 - Smokers on premises

Provide details

10.2 - Hazardous substances on site

Provide details

Sign Off
Staff Member's Name
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.