AGC Home Safety Assessment

Home Safety Assessment
MonthDayYear
Date
Client’s Name*

First NameLast Name
Key: Check box if satisfactory; mark "n/a" if not applicable
Environment
Stairway:

BanisterCarpetLightingObstruction-freeRamp
Home:

Furniture PlacementVentilationHeating/ACLightingRugs/Carpeting/FlooringTelephoneEmergency NumbersWaterPlumbingGeneral Cleanliness
Recommendations:
Medication
Medication/Supplies safely storedMedication self-administrationMedication Reminders Needed (add to Plan of Care)
Recommendations:
Fire Safety
Smoke DetectorExits IdentifiedTraffic Patterns ClearFire ExtinguisherWheelchair Access
Recommendations:
Bath / Bedroom
Hazard-free access to:

Toilet / BathroomBedroomNon-slip surface on tub/shower/floors
Recommendations:
Kitchen
Food Preparation AreaRefrigeratorStove/MicrowaveGarbage Removal
Recommendations:
The undersigned certifies that he/she has read and received a copy of the foregoing, and is the Client, or is duly authorized by the Client's general agent to execute the above and accept its terms.
Client’s Name*

First NameLast Name
Signature of Client:*

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Name of Client’s Representative

First NameLast Name
Signature of Client’s Representative:

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Name of AGCHC Representative:

First NameLast Name
Should be Empty: