Home Safety & Health
Yes
No
1. Knives, tools, matches, and other potentially hazardous materials are inaccessible
to children, unless used with appropriate supervision. (FDC, FFH)
Yes
No
2. Combustible items are properly stored at least 36" from any heating sources.
Yes
No
3. Food is handled and properly stored to prevent contamination, spoilage, or a
threat to health.
Yes
No
4. Residence is clean and free from accumulations of dirt, rubbish, peeling paint,
rodents and insects.
Yes
No
5. Chemicals, detergents, medicines, and other toxic substances are stored sepa-
rately from food products. When appropriate, these substances are inaccessible
to clients.
Yes
No
6. Any Schedule II controlled substances are stored in a locked area. (AFC)
Yes
No
7. There is a safe water supply in the residence; water from privately-owned wells
is tested annually by a certifi ed laboratory.
Yes
No
8. Individual clean towels, wash cloths, and bedding are provided for each client.
Yes
No
9. Weapons and ammunition are stored separately in locked areas.
Remarks (Please explain all "NO" answers): ___________________________________
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Obvious safety hazards or concerns?: _________________________________________
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Provider Signature:
Date
LicensingWorker:
Date