HOME SAFETY ASSESSMENT FORM / ESTIMATE
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Type of Form to Use
Home Assessment & Estimate
Pro Services Job Estimate
Date of Assessment
/
Month
/
Day
Year
Date
Lead Status
Pending Service
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Contact ID
Assessor / CAPS: Name
Contractor
Project
Client Information
First Name
Last Name
Phone
Address
City
Zip
MemberID
Emergency Contact
Phone
Household Information
Home Type
Single Family Home
Manufactured/Mobile Home
Apartment
Other
Owns Home
Yes
No
Lives Alone
Yes
No
Number of people in home
Ages
Uses Mobility Device/s:
None
Cane
Walker
Wheelchair
Other
Primary Medical Concerns
1. EXTERIOR ENTRANCES AND EXITS AREA
Needs Attention: YES
Needs Attention: NO
Walkway / Driveway Condition
Steps secure and in good condition
Handrails Present and secure
Adequate lighting
Door threshold height (over 1/2")
Ability to use doorknob/lock/key
House numbers visible from street
Bushes trimmed for safe access
Recommended Modifications:
Install Handrails
Repair Walkway
Install Ramp
Add Lighting
Install Lever Door Handle/s
Other
2. INTERIOR PATHWAYS, STAIRS, HALLS AREA
Needs Attention: YES
Needs Attention: NO
Clear pathways between rooms
Secure floor surfaces/no trip hazards
Adequate lighting
Stairs in good condition
Handrails secure on both sides
Hallways wide enough for mobility
Door thresholds under 1/2"
Floor transitions safe
Recommended Modifications:
Remove Clutter
Secure Rugs
Install Handrails
Improve Lighting
Install Lever Door Handle/s
Repair Stairs
Widen Doorways
Other
3. BATHROOM/S AREA
Needs Attention: YES
Needs Attention: NO
Ability to get on / off toilet
Grab bars at toilet
Grab bars in shower / tub
Non-slip surface shower / tub
Ability to step in / out of shower / tub
Ability to use faucets
Bathroom door width adequate
Adequate lighting
Recommended Modifications:
Install Grab Bars at Toilet
Install Grab Bars at Shower / Tub
Install Hand-Held Shower Head
Improve Lighting
Install Lever Door Handle/s
Add Non-Slip Surface
Raise Toilet Height
Install Lever Faucets
Other
4. KITCHEN AREA
Needs Attention: YES
Needs Attention: NO
Ability to reach cabinets / shelves
Ability to use sinks / faucets
Ability to use stove / oven safely
Adequate counter space
Accessible storage
Adequate lighting
Recommended Modifications:
Improve Lighting
Install Lever Faucets
Reorganize Storage
Adjust Cabinet Heights
Other
5. LIVING AREA & BEDROOM/S
Needs Attention: YES
Needs Attention: NO
Furniture at appropriate height
Ability to get in / out of bed
Ability to get in / out of chairs
Secure rugs / no trip hazards
Clear pathways
Adequate lighting
Access to telephone
Ability to operate light switches
Recommended Modifications:
Raise Furniture Height
Secure Rugs
Improve Lighting
Install Bedside Assistance
Other
6. SAFETY & SECURITY
Needs Attention: YES
Needs Attention: NO
Working smoke detectors
Working C02 detectors
Secure locks on doors / windows
Hot water temp safe
Electrical hazards (cords etc.)
Emergency exit plan
Pest control issues
Recommended Modifications:
Install / Replace Smoke Detectors
Install / Replace C02 Detectors
Secure / Replace Locks
Lower Water Heater Temp
Address Pest Issue
Other
SUMMARY OF RECOMMENDATIONS
Contractors Notes
EQUIPMENT RECOMMENDED
QTY
Notes
Shower Chair
Handheld Shower Wand
Toilet Riser
Grab Bars
Bed Rail
Transfer Bench
Shower Mat
Ramp
Other
Estimate
AUTHORIZATION
I authorize Rebuilding Together Rogue Valley to submit this assessment to my insurance provider.
Yes
No
Home Assessment Completed:
Yes
No
Pending Service
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