NDIS Home Safety Risk Assessment Form
PARTICIPANT DETAILS
Name
First Name
Last Name
DOB
-
Day
-
Month
Year
Date
NDIS Number
Participant Address
POTENTIAL ISSUES
Access to residence (select all that apply)
*
Difficulty finding the street or property
Obstacles to front door access
Issues with outdoor lighting
Blocked/missing exit in case of emergency
Uneven/slippery pathways, verandah or stairs
Narrow paths/stairs
Issue with opening door
Poor mobile reception
Pets/animals on property
Entry/hallway obstructed
Mat/carpet unsafe/unsecured
Other
None
If Other, please specify
Additional information for any items selected above
Occupants (select all that apply)
*
Client mobility issues/wheelchair
Other occupants
Known weapons/firearms
Known issues of substance misuse for client
Known issues of substance use for other occupant(s)
Interpreter required for client
Relevant cultural/religious sensitivities
Client smoking
Other occupant(s) smoking
Manual handling risks
Personal care risks
Other
None
If Other, please specify
Additional information for any items selected above
Interior areas (select all that apply)
*
Poor/broken interior lighting
Obstructed exits
Broken/poorly placed heating
Lack of appropriate/well maintained equipment and aids
Unstable/unsafe furniture
Slip/trip hazards
Faulty/inaccessible power points and electrical cords
Poor/inadequate ventilation and drainage
Unsuitable/unclean benches/surfaces
Inaccessible or unsafe bath/shower/toilet
Unclean kitchen/inappropriate food storage
Unsecure storage/unlabeled chemicals
Other
None
If Other, please specify
Additional information for any items selected above
RISK MITIGATION/ACTION PLAN
Are there any current plans/strategies in place to mitigate the risks identified above? (please detail here)
Risk Action Plan (OFFICE USE ONLY)
Rows
Identified Risk
Risk Rating (High, Medium, Low)
Action Required
Completed By
Completed Date
1
2
3
4
5
6
7
ACKNOWLEDGEMENT
TO BE COMPLETED ONCE ACTION PLAN IS CONFIRMED
Do you agree to the Action Plan above?
Yes
No
Form Completed By
First Name
Last Name
Completed On
-
Day
-
Month
Year
Date
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