FRANKLIN COUNTY SAFETY CHECKLIST - Open Door/Supported Living
Resident Name
*
First Name
Last Name
Resident Name
First Name
Last Name
Resident Name
First Name
Last Name
Resident Name
First Name
Last Name
Resident Name
First Name
Last Name
Address of the SCL location for this form
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
DODD #: 2500243
FRANKLIN COUNTY BDD MONTHLY SAFETY CHECKLIST
*
YES
NO
All walk areas clear and free of debris/clutter?
At least one Bedroom window has clear access for emergency egress?
Fire extinguisher present, fully charged, inspected, and tagged?
Smoke detectors present and in working order?
Stove and range exhaust hood are free from grease build up?
Home is clean?
Any unmet maintenance needs?
Dryer Lint traps are free from lint and build up?
Safe smoking practices area observed?
Date on fire extinguisher tag:
*
-
Month
-
Day
Year
Date
Number of smoke detectors in home:
*
Date smoke detectors tested/inspected:
*
-
Month
-
Day
Year
Date
EXPLANATION ON ANY CONCERNS OR ISSUES LISTED ABOVE:
Open Door/SCL staff completing form-name:
*
First Name
Last Name
Email of Open Door/SCL staff completing form:
*
example@example.com
Date form completed:
*
-
Month
-
Day
Year
Date
Franklin County SSA Name
*
First Name
Last Name
Franklin County SSA email
*
example@example.com
Submit
Should be Empty: