Client Home Visit – Risk Assessment Form
General Info
Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (0000) 000-000.
Email
example@example.com
Back
Next
Access to Property
Address
Usual Address
Please Select
Yes
No
Usual address means you have regular address;
Type of Accommodation
SIL House
House
Unit
Apartment
Caravan
Boarding house
Other
Who else live here:
Partner
Parents
Housemate(s)
Carer
Children
Other
Rows
YES
No
Risk Level
Comment/ Risk Identify
Control measure
Can the house be seen from the street?
5
4
3
2
1
Is the house easily identifiable?
5
4
3
2
1
Is there good street lighting?
5
4
3
2
1
Is there parking close by?
5
4
3
2
1
Are there a large number of stairs?
5
4
3
2
1
Does a lift need to be used?
5
4
3
2
1
Is entry via the front door?
5
4
3
2
1
Will someone be able to open the front door?
5
4
3
2
1
Will anyone else be home during the visit?
5
4
3
2
1
Does anyone at home have a contagious illness?
5
4
3
2
1
Will anyone at home be upset by the visit?
5
4
3
2
1
Does anyone at home take drugs or drink a lot of alcohol?
5
4
3
2
1
Does anyone at home smoke?
5
4
3
2
1
Are there any animals living at home? If yes, can they be restrained / put outside during the visit?
5
4
3
2
1
Is a phone call needed prior to the visit to allow for animals to be restrained / moved?
5
4
3
2
1
Is there mobile phone coverage at the house?
5
4
3
2
1
Does the person being visited have a history of violence or aggression?
5
4
3
2
1
Is there a requirement for DCNC staff to attend the visit?
5
4
3
2
1
Is there clear access to exits (in case of an emergency)
5
4
3
2
1
Are there any previously identified alerts or risks related to this property or person?
5
4
3
2
1
Total Risk Score
Staff Name
Date
-
Month
-
Day
Year
Date
Signature
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