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Service Environment / Home Safety Checklist

This form is intended to assess the safety of the service environment. Using this form, we will be able to evaluate the service environment in terms of its overall safety for participants and workers providing support services.

Completion Guidelines

In the event of an Emergency/Urgent/Imminent Danger that may cause death and/or a serious injury, halt this inspection and deal with the emergency as appropriate and necessary, the situation must be guarded and rectified immediately.

Report the issue to the responsible Manager, and document it in this form after the hazard has been adequately handled.

  1. Review the previous home safety checklist to identify any outstanding actions.
  2. If the situation meets the requirements, indicate it in the ‘Yes’ column. If it does not meet the requirements, mark it in the “No” column and describe why it did not meet the requirements in the comment/action section.
  3. In the comments/actions section, also indicate what action is necessary to address the issue.
  4. Sign off on the Checklist to retain a copy of the document in the client’s file. (The Supervisor may provide additional comments in the Notes/Additional Issues section, if necessary.)
  5. You may identify major outcomes from this assessment at the client team meeting.
Date of Inspection
Address