Home Risk Assessment Checklist

Home Risk Assessment Checklist

MUST be completed objectively and in consultation with the participant or their representative. There is a risk matrix and other resources at the bottom of this risk assessment form.
Is this support in-home, or does it require pickup/drop-off? If this doesn’t apply, you don’t need to complete the whole form only required fields — simply sign off at the end.*
Date of risk assessment completion*

DayMonthYear
Date
Participant's name*
Participant's phone number
Participant address
Mildura Disability Support Staff Name & Position: (If Applicable)
MDS Staff contact number
YesNo
Is this risk assessment the first visit by any MDS staff to the home? If home has been visited before, provide further information regarding any risks encountered.
ViolenceTheftVandalismThreatening or disruptive behaviourLewd or inappropriate behaviourUse or display of weaponsSubstance abuseNone of the aboveOther
Comments
Please rate the risk of high risk behaviours or incidents occurring:
Please write the participant/representative response to the identified risk and possible mitigation strategies for them, if any, as well as any further information:
Q1 - Is the property difficult to access? (unit complex, long driveway, gated, muddy driveway, etc) - is this a risk or a barrier to supports being provided? Rate L/M/H/E
Q1 - Participant response and proposed mitigation strategies
Q2 - Is there anything in or around the house that may pose a risk of slips, trips or falls? Rate L/M/H/E
Q2 - Participant response and proposed mitigation strategies
Q3 - Does the participant smoke? Rate the risk level L/M/H/E
Q3 - If the participant does smoke, can a smoke free environment be maintained whilst supports are provided? (provide proposed mitigation strategies)
Q4 - Will any manual handling be required by MDS staff whilst providing supports? Rate the potential risk as L/M/H or E
Q4 - propose mitigation strategies if a risk is present.
Mildura Disability Support Services I Home Risk
Q5 - are there any pets or animals in and around the property who may pose a health and safety risk? Rate this L/M/H/E
Q5 - propose mitigation strategies
Q6 - Does the required support and/or the home environment necessitate the use of Personal Protective Equipment (PPE)?
Q6 - Is there a risk present? If yes, include risk level. Rate the risk as L/M/H/E
Q6 - propose mitigation strategies
Q7 - are there any other relevant risks that should be considered? List and rate these L/M/H/E
Q7 - propose mitigation strategies
Mildura Disability Support Services I Home Risk
Communication with Client
Date and time of home risk assessment visit
Address being risk assessed
Who else is present? (names of participant, representative, other MDS staff etc)
Assessment endorsement
Assessment endorsement: I have reviewed the above information and support the conduct of this in-home service as per this risk assessment:
Assessment endorsement: Reason/s for the decisions to proceed/not proceed with the in-home service:*
Assessment endorsement: Worker completing Home Risk Assessment Checklist name
Assessment endorsement: Worker signature

Clear
Date*

DayMonthYear
Date
Name of Participant or Representative filling out form *

First NameLast Name
Participant or Representative Signature *

Clear
Mildura Disability Support Services I Home Risk

Table 1

Risk Matrix

Likelihood	Consequences
Likelihood	Insignificant	Minor	Moderate	Major	Critical

Almost certain	Medium	Medium	High	Extreme	Extreme
Likely	Low	Medium	High	High	Extreme
Possible	Low	Medium	Medium	High	High
Unlikely	Low	Low	Medium	Medium	High
Rare	Low	Low	Low	Low	Medium

Table 2

	Insignificant	Minor	Moderate	Major	Critical
Consequence of occurence	No medical treatment required	Minor injury requiring first aid treatment (e.g. minor cuts, bruises, bumps)	Injury requiring medical treatment	Serious injury (injuries) or hospitalisation	Loss of life permanent disability or multiple serious injuries

Table 3

	Insignificant	Minor	Moderate	Major	Critical
Likelihood of occurences	Will only occur in exceptional circumstances	It is not likely to occur within the forseeable future	May occur within the forseeable future	It is likely to occur within the forseeable future	It is almost certain to occur within the forseeable future

Table 4

Current risk level	Mitigate	Report
Extreme	in-home service not to be undertaken.	Review in-home service with the Director/Supervisor, update systems and complete a Workplace incident report if needed.
High	Only proceed with providing support and services at the Workplace with the Director or senior staff member’s approval. The risks associated with the Workplace must be re-assessed & other options considered	Review in-home service with the Director/Supervisor, update systems and complete a Workplace incident report if needed.
Medium	Workplace should only be used after consultation with the Director. The risks should be reviewed to take into account all the hazards involved. The risks must be reduced prior to the provision of services or support at the Workplace. If in doubt, re-classify as High Risk.	Provide risk update to management, as required.
Low	Workplace acceptable. Ensure control options are followed.	Provide risk update to management, as required.

Mildura Disability Support Services I Home Risk
Should be Empty: