Self Contained Room handover checklist

• Document No.

• Conducted on

  Date

• Prepared by

• UNIT

• Room

• Resident moving into room

  Yes/No

• Resident moving out of the room

  Yes/No

• Resident present at time of inspection

  Yes/No

• Fire door condition

  GOOD

  NEEDS REPAIRS

  DAMAGED BY RESIDENT

• SPECIFY

• SPECIFY

• Carpet/Vinyl Condition

  GOOD

  WORN

  NEEDS CLEANING

  SOILED

  DAMAGED BY RESIDENT

• SPECIFY

• Chest of drawers

  GOOD

  NEEDS REPAIRS

  DAMAGED BY RESIDENT

• SPECIFY

• SPECIFY

• Wardrobe

  GOOD

  NEEDS REPAIRS

  DAMAGED BY RESIDENT

• SPECIFY

• Condition of bed

  Good

  Needs repairs

  Damaged

• Condition of matress

  Select Good Fair Poor Damaged by resident Missing Too long - fire hazard

  • Good
  • Fair
  • Poor
  • Damaged by resident
  • Missing
  • Too long - fire hazard

• Condition of bedside cabinet

  GOOD

  NEEDS REPAIRS

  DAMAGED BY RESIDENT

• SPECIFY

• SPECIFY

• Lights

  GOOD

  NEEDS REPAIRS

  DAMAGED BY RESIDENT

• SPECIFY

• Heaters

  GOOD

  NEEDS REPAIRS

  DAMAGED BY RESIDENT

• SPECIFY

• Condition of Walls

  GOOD

  NEEDS REPAIRS

  DAMAGED BY RESIDENT

• SPECIFY

• SPECIFY

• Condition of Ceilings

  GOOD

  NEEDS REPAIRS

  DAMAGED BY RESIDENT

• SPECIFY

• SPECIFY

• Condition of smoke detector

  GOOD

  DIRTY

  DEEP CLEAN REQUIRED

• SPECIFY

• Condition of Windows

  Select GOOD DIRTY NEEDS REPAIRS DAMAGED BY RESIDENT

  • GOOD
  • DIRTY
  • NEEDS REPAIRS
  • DAMAGED BY RESIDENT

• SPECIFY

• Specify

• SPECIFY

• Condition of Blinds / curtains

  Select Good Fair Poor Damaged by resident Missing Too long - fire hazard

  • Good
  • Fair
  • Poor
  • Damaged by resident
  • Missing
  • Too long - fire hazard

• Specify

• Rectify

• Management informed?

  Yes/No

• MANAGEMENT INFORMED?

• Condition of bathroom door

  GOOD

  NEEDS REPAIRS

  DAMAGED BY RESIDENT

• SPECIFY

• SPECIFY

• Condition of bathroom Sink

  GOOD

  DIRTY

  NEEDS REPAIRS

  DAMAGED BY RESIDENT

• Specify

• SPECIFY

• Condition of Toilet

  GOOD

  DIRTY

  NEEDS REPAIRS

  DAMAGED BY RESIDENT

• Specify

• SPECIFY

• Condition of shower enclosure

  GOOD

  DIRTY

  NEEDS REPAIRS

  DAMAGED BY RESIDENT

• Shower head requires descaling

  Yes/No

• Condition of mirrored Bathroom cabinet

  GOOD

  NEEDS REPAIRS

  DAMAGED BY RESIDENT

• Cooker in good working order

  GOOD

  NEEDS REPAIRS

  DAMAGED BY RESIDENT

• Cooker requires cleaning

  Yes/No

• Condition of worktop

  GOOD

  DIRTY

  NEEDS REPAIRS

  DAMAGED BY RESIDENT

• Condition of kitchen sink

  GOOD

  DIRTY

  NEEDS REPAIRS

  DAMAGED BY RESIDENT

• Room cleaning

  CLEAN

  FAIR

  DIRTY

  DEEP CLEAN REQUIRED

• Are there electrical items in the room that require PAT Testing?

  yes

• STAFF Signature

  Sign

• Maintenance Tech Signture

  Sign

Resident Signature

• I AM AWARE OF ITEMS ABOVE

  Sign