Ngaanyatjarra Health Service

• Conducted on

  Date

• Prepared by

• Location
  Address

• EH Practitioner

• Community

• Date

  Date

• House address

• Number of people living in house at time of inspection

• Shower taps

  Yes

  No

  N/A

• Hot tap

  Select Yes No N/A

  • Yes
  • No
  • N/A

• Action

  Fix

  Replace

  Clean

  Refer

• Cold tap

  Select Yes No N/A

  • Yes
  • No
  • N/A

• Action

  Fix

  Replace

  Clean

  Refer

• Hot water flow

  Select Yes No N/A

  • Yes
  • No
  • N/A

• Action

  Fix

  Replace

  Clean

  Refer

• Cold water flow

  Select Yes No N/A

  • Yes
  • No
  • N/A

• Action

  Fix

  Replace

  Clean

  Refer

• Shower rose works

  Select Yes No N/A

  • Yes
  • No
  • N/A

• Action

  Fix

  Replace

  Clean

  Refer

• Shower drain works

  Select Yes No N/A

  • Yes
  • No
  • N/A

• Action

  Fix

  Replace

  Clean

  Refer

• Grate

  Select Yes No N/A

  • Yes
  • No
  • N/A

• Action

  Fix

  Replace

  Clean

  Refer

• Shower Soap holder

  Select Yes No N/A

  • Yes
  • No
  • N/A

• Action

  Fix

  Replace

  Clean

  Refer

• Hand basin

  Select Yes No N/A

  • Yes
  • No
  • N/A

• Action

  Fix

  Replace

  Clean

  Refer

• Basin is safe

  Select Yes No N/A

  • Yes
  • No
  • N/A

• Action

  Fix

  Replace

  Clean

  Refer

• Basin taps

  Select Yes No N/A

  • Yes
  • No
  • N/A

• Hot tap

  Select Yes No N/A

  • Yes
  • No
  • N/A

• Action

  Fix

  Replace

  Clean

  Refer

• Cold tap

  Select Yes No N/A

  • Yes
  • No
  • N/A

• Action

  Fix

  Replace

  Clean

  Refer

• Hot water flow

  Select Yes No N/A

  • Yes
  • No
  • N/A

• Action

  Fix

  Replace

  Clean

  Refer

• Cold water flow

  Select Yes No N/A

  • Yes
  • No
  • N/A

• Action

  Fix

  Replace

  Clean

  Refer

• Basin cabinet is present

  Select Yes No N/A

  • Yes
  • No
  • N/A

• Cabinet is functional

  Select Yes No N/A

  • Yes
  • No
  • N/A

• Action

  Fix

  Replace

  Clean

  Refer

• Basin drain works

  Select Yes No N/A

  • Yes
  • No
  • N/A

• Action

  Fix

  Replace

  Clean

  Refer

• Floor surface

  Safe

  At Risk

  N/A

• Floor waste

  Select Yes No N/A

  • Yes
  • No
  • N/A

• Action

  Fix

  Replace

  Clean

  Refer

• Grate

  Select Yes No N/A

  • Yes
  • No
  • N/A

• Action

  Fix

  Replace

  Clean

  Refer

• Floor waste works

  Select Yes No N/A

  • Yes
  • No
  • N/A

• Action

  Fix

  Replace

  Clean

  Refer

• Mirror present

  Select Yes No N/A

  • Yes
  • No
  • N/A

• Action

  Fix

  Replace

  Clean

  Refer

• Mirror is safe

  Select Safe At Risk N/A

  • Safe
  • At Risk
  • N/A

• Fix

  Replace

  Clean

  Refer

• Kids can see their face

  Select Yes No N/A

  • Yes
  • No
  • N/A

• Towel rail / hooks

  Select Yes No N/A

  • Yes
  • No
  • N/A

• Action

  Fix

  Replace

  Clean

  Refer

• Towels can be hung up

  Select Yes No N/A

  • Yes
  • No
  • N/A

• Towels can be hung seperately

  Select Yes No N/A

  • Yes
  • No
  • N/A

• Is there a shower screen

  Select Yes No N/A

  • Yes
  • No
  • N/A

• Action

  Fix

  Replace

  Clean

  Refer

• Does it work

  Select Yes No N/A

  • Yes
  • No
  • N/A

• Action

  Fix

  Replace

  Clean

  Refer

• It is clean

  Select Yes No N/A

  • Yes
  • No
  • N/A

Soap was present

• In the Shower

  Yes

  No

  N/A

• At the Basin

  Yes

  No

  N/A

• How many people use this bathroom ?

• Does everyone have their own towel ?

  Yes

  No

  N/A

• Can each towel be hung up in the bathroom ?

  Yes

  No

  N/A

• Did you install towel hangers or towel rails ?

  Yes

  No

  N/A

• How many towels given to this house ?

• How many bars of soap given to this house ?

• Are soap holders installed

  Yes

  No

  N/A

• How many soap holders

• New mirror installed ?

  Yes

  No

  N/A

• Face and Hand washing sticker in place?

  Yes

  No

  N/A

• Did you replace the Face and Hand washing sticker?

  Yes

  No

  N/A

• Did you have a conversation about Face and Hand washing?

  Yes

  No

  N/A