In-Home Safety Assessment for Seniors
Resident Information
Name
Date of Birth
Address
Phone
General Assessment
Assessor Name
Date of Assessment
Bathroom Safety
Grab bars in place
Non-slip mats
Accessible shower/tub
Notes
Bedroom Safety
Clear pathways
Night light available
Bed at safe height
Notes
Living Area Safety
Loose rugs secured
Electrical cords out of way
Smoke alarms functional
Notes
Kitchen Safety
Fire extinguisher accessible
Appliances in good repair
Frequently used items easy to reach
Notes
Other Concerns / Recommendations
Comments