Home Safety Checklist Template (Page 2 of 2) in pdf

Home Safety & Health

Yes

1. Knives, tools, matches, and other potentially hazardous materials are inaccessible

to children, unless used with appropriate supervision. (FDC, FFH)

Yes

2. Combustible items are properly stored at least 36" from any heating sources.

Yes

3. Food is handled and properly stored to prevent contamination, spoilage, or a

threat to health.

Yes

4. Residence is clean and free from accumulations of dirt, rubbish, peeling paint,

rodents and insects.

Yes

5. Chemicals, detergents, medicines, and other toxic substances are stored sepa-

rately from food products. When appropriate, these substances are inaccessible

to clients.

Yes

6. Any Schedule II controlled substances are stored in a locked area. (AFC)

Yes

7. There is a safe water supply in the residence; water from privately-owned wells

is tested annually by a certiﬁ ed laboratory.

Yes

8. Individual clean towels, wash cloths, and bedding are provided for each client.

Yes

9. Weapons and ammunition are stored separately in locked areas.

Remarks (Please explain all "NO" answers): ___________________________________

___________________________________________________________________________

Obvious safety hazards or concerns?: _________________________________________

___________________________________________________________________________

Provider Signature:

Date

LicensingWorker:

Date

Home Safety Checklist Template Page 2