Home Checklist

This checklist is completed with the customer and / or guardian at intake stage prior to commencement of service. The checklist is to be used as a guide in identifying hazards / risks to include in the home risk assessment.

The customer is responsible for informing Roar Agency if there are any changes to their home environment which will impact this checklist and / or the Risk Assessment.

Staff are required to read the Risk Assessment prior to working with a customer in their home.

Date *

Are you a Staff member completing this form? *NoYes

Customer name and / or guardian(s) present: *

Staff member completing checklist:

Type of residence: *

HouseUnitAged Care FacilityCaravan ParkOther

Please describe

ACCESS TO PROPERTY AND CUSTOMER

Are street signs or numbers hidden from view? *NoYes

Is the house hidden from the street? *NoYes

Is street parking prohibited or unavailable for staff? *NoYes

Are there uneven / dangerous paths leading to house? *NoYes

Are there any dangerous or slippery steps? *NoYes

Does the customer have any cultural or religious considerations? *NoYes

Are there harmful chemicals that staff are expected to use to assist with cleaning? *NoYes

ANIMALS AND PETS

Any animals with open access to front of property or inside house? *NoYes

RESIDENTS AND GUESTS

Is it likely that people in the home will be smoking, vaping or drinking alcohol during our visit? *NoYes

Is there known substance abuse amongst people in the home? *NoYes

HOME SAFETY

Are there working smoke detectors in the house as required by legislation? *NoYes

Are all appliances clean and in safe and working order? *NoYes

Are there handwashing facilities available for staff? *NoYes

Acknowledgement

Staff Member Name

Staff Member Signature

Start signing your signature here

Customer / Guardian Name *

Customer / Guardian Signature *

Start signing your signature here

Date *

Day *

Month *

Year *

Our Mission is to encourage and empower people to live their best lives

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