* Required Information
Full Name
*
How is the lighting in the home, entrance, and walkway areas?
Does the home have a fire extinguisher?
Yes
No
When last recharged?
Does the home have WORKING smoke/carbon monoxide detectors?
One
Two
More
Do you encourage your participant to exercise and eat a healthy diet?
Have you offered to help participant keep up to date with their medications?
Is the pavement uneven where the participant must walk?
Do you ask and/or plan with the participant when they may need your assistance when walking, standing, or transferring?
Often
Always
Do the stairs inside or out (if applicable) have a secure rail or bannister?
Does the home have fringes on throw rugs, any loose carpeting, or floorboards?
Is there a rail or support bar on the bathtub or shower?
Are there items stored on the stairs or clutter?
Yes
No
Sanitation / Health Aide Supplies
First Aid Kit
Yes
No
Mask
Yes
No
Gloves
Yes
No
Hand sanitizer
Yes
No
Disinfectant sprays or wipes
Yes
No
Are household products stored properly?
Yes
No
Is the Participant safe in this environment?
Yes
No