Risk Assessment
Participant Name
First Name
Last Name
Date of Birth
-
Day
-
Month
Year
Date
Gender
Male
Female
Other
Info
Probability Levels
{Occasional: Happens rarely but is possible.} {Common: Occurs regularly in similar circumstances.} {Frequent: Very likely to happen frequently.}
Impact Levels
{Minor: Minimal impact on service delivery. No injury or very minor inconvenience.} {Moderate: Some disruption to service. Minor injuries or temporary discomfort.} {Major: Significant disruption. Severe injury requiring medical attention.}
PRE-VISIT ASSESSMENT
Are there any pets at the property that may pose a risk to injuring a staff member?
Yes
No
Probability
Please Select
Occational
Common
Frequent
Impact
Please Select
Minor
Moderate
Major
Notes
*
What type of pet do you have, and will it be kept in a separate area during the appointment?
Does the participant consume alcohol or illicit substances?
Yes
No
Probability
Please Select
Occational
Common
Frequent
Impact
Please Select
Minor
Moderate
Major
Notes
*
Note: Are there drugs kept on premises, if so, can it be removed?Caution: During the appointment Participant should not be intoxicated or under the influence of any drug.
Does the participant or other residents of the home have a history of aggressive violent or sexual behaviour?
Yes
No
Probability
Please Select
Occational
Common
Frequent
Impact
Please Select
Minor
Moderate
Major
Notes
*
If yes, please provide details including the nature of the behaviour, who was involved, how often it occurs, and any strategies currently in place to manage the behaviour. Are there any precautions that the therapist need to take?
Is there physical or verbal aggressive behaviour?
Yes
No
Probability
Please Select
Occational
Common
Frequent
Impact
Please Select
Minor
Moderate
Major
Notes
*
If yes, please provide details, including who is involved, the frequency of the behaviour, triggers (if known), and any strategies currently used to manage it. Are there any precautions that the therapist need to take?
Is the house inaccessible by a small car?
Yes
No
Notes
*
If no, please describe any access limitations (e.g., narrow roads, steep driveways, lack of parking).
Are there any weapons located at the property? If so, are they safely locked away?
Yes
No
Probability
Please Select
Occational
Common
Frequent
Impact
Please Select
Minor
Moderate
Major
Notes
*
If yes, please specify the type and confirm whether they are securely stored and locked away.
Are there issues with mobile reception at the property?
Yes
No
Probability
Please Select
Occational
Common
Frequent
Notes
*
Are there any environment hazards? eg. Stairs, electricity, fire.
Yes
No
Probability
Please Select
Occational
Common
Frequent
Impact
Please Select
Minor
Moderate
Major
Notes
*
For example: stairs, exposed electrical wiring, fire risks, or other safety concerns. Please provide details.
Does the participant have a behaviour support or behaviour management plan?
Yes
No
Probability
Please Select
Occational
Common
Frequent
Impact
Please Select
Minor
Moderate
Major
Notes
*
If yes, please provide a copy or summary of the plan, including key strategies and support requirements. Are there any common triggers that we should know?
Are there restrictive practices in places?
Yes
No
Probability
Please Select
Occational
Common
Frequent
Impact
Please Select
Minor
Moderate
Major
Notes
*
If yes, please provide details and indicate whether they are authorised as part of a Behaviour Support Plan?
Is there any medical conditions that we need to be aware about? E.g., allergy from nuts, seizures, Infectious diseases
Yes
No
Probability
Please Select
Occational
Common
Frequent
Impact
Please Select
Minor
Moderate
Major
Notes
*
For example: allergies (e.g., nuts), seizures, or any infectious diseases. Please provide details, including any required precautions or emergency procedures. If so, is there a medical action plan?
Are there other identified risks not already mentioned?
Yes
No
Probability
Please Select
Occational
Common
Frequent
Impact
Please Select
Minor
Moderate
Major
Notes
*
If yes, please provide details to help us ensure appropriate support and safety measures are in place.
Submit
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