Healthy Homes Checklist for Residential Properties (long version)

Healthy Homes Checklist for Residential Properties (long version)

Observational checklist for community healthcare workers
This is a hidden field that users of the form can't see.

The owner of this form is Shareen Elnagy
Complete the checklist using both:
- What you observe when entering the property and checking each room
- What the resident tells you when asked or voluntarily discloses
Do not move furniture, inspect building elements or diagnose technical problems.

Tick any item that applies even if you are not 100% sure.

Add brief comments if helpful, including locations of damp, mould or other concerns.

If one or more concerns are identified, consider referral to Warm & Safe Wiltshire or your local support service. Obtain the resident's consent before making a referral.

Follow safeguarding procedures if there is an immediate risk to the residents’ health or safety.
Referrer's name

First NameLast Name
Referrer's job role
Referrer's email
Resident's address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Resident's name

First NameLast Name
Resident's phone number and/or email
Date

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
Today's weather (Helps to provide context on indoor conditions)
1. Damp and mould
If you ticked any of the boxes from the list above, please note the location of the problem and any other relevant information here.
2. Ventilation and air quality
Comments.
3. Cold home risks
Comments.
4. Excess heat risks
Comments.
5. Safety and wellbeing indicators
Comments.
Action Required?
If you ticked the escalation box above, please give details
If you ticked Refer to Warm & Safe Wiltshire, please tell us which service.

Other
If you selected 'Other' please give details
Add details to the option(s) you selected in the question above.
If you're referring a client, please tick the box below to confirm that permission has been granted by the client to share their details. For more information about how we use personal information please see CSE's privacy policy.
Should be Empty: