Risk Assessment Form

Risk Assessment Form

Pre- Home Visit
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Accommodation type-
Is the house visible from the street?

YesNo
Are there any hazards accessing the home? i.e. rough driveway, low hanging branches, steps

NoYes
If yes, please give details-
Will area by well lit if accessing the home in low light, or at night?

YesNo
Will someone be able to open the door?

YesNo
If no, please provide details of how we should access your home-
Is there adequate parking outside your property?

YesNo
If no, please provide details of where we should park-
Is there phone reception at your property?

YesNo
Do you have pets at your property?

NoYes
If yes, do you agree to secure pets away from the nurse for the duration of the visit?

YesNo, 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-

YesNo, if no, services will not be possible as per federal law.
Does anyone in the house smoke?

NoYes, if yes, please observe no smoking rule for the duration of the nurses visit.
Are there any religious beliefs or practices to be considered?

NoYes
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?

NoYes. 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

YesNo, unfortunately services will not be able to be delivered.
Any other comments or things you think we should know-
I agree that the above is true and correct-

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Thank you for taking the time to complete this form, we value your contribution to providing a safe working environment for our staff.
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