Risk Assessment Form
Pre- Home Visit
Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Accommodation type-
Is the house visible from the street?
Yes
No
Are there any hazards accessing the home? i.e. rough driveway, low hanging branches, steps
No
Yes
If yes, please give details-
Will area by well lit if accessing the home in low light, or at night?
Yes
No
Will someone be able to open the door?
Yes
No
If no, please provide details of how we should access your home-
Is there adequate parking outside your property?
Yes
No
If no, please provide details of where we should park-
Is there phone reception at your property?
Yes
No
Do you have pets at your property?
No
Yes
If yes, do you agree to secure pets away from the nurse for the duration of the visit?
Yes
No, if no, services will not be possible, please contact us on 0402 882 076 to discuss if this is a concern for you
I agree to secure any guns or other weapons in their appropriate containment as required by law for the duration of the visit-
Yes
No, if no, services will not be possible as per federal law.
Does anyone in the house smoke?
No
Yes, if yes, please observe no smoking rule for the duration of the nurses visit.
I agree to the no smoking rule for the duration of the nurses visit.
Are there any religious beliefs or practices to be considered?
No
Yes
If yes, please provide details-
Is it likely that you or other occupants will be under the influence of alcohol or other drugs during the nurses visit?
No
Yes. If yes, the nurse may refuse to visit if the situation is deemed unsafe. Full payment will be required if a safe workplace cannot be provided for the scheduled service, or please call within 24 hours of service commencement to avoid fee payment.
Melinda Webb Support Service nurses do not provide assistance with manual handling. I agree to provide my own manual handling
Yes
No, services will not be able to be delivered.
Any other comments or things you think we should know-
Submit
Should be Empty: