In-Home Safety Evaluation Form

Resident Name

Date

Address

Evaluator Name

1. Entryways

Entryways clear of obstacles Door locks functioning properly Ramps/steps in good repair

2. Lighting

Adequate hallway lighting Adequate room lighting Nightlights in use where needed

3. Bathroom Safety

Grab bars present/secure Non-slip mats in tub/shower Toilet height accessible

4. Kitchen Safety

Appliances working safely Counters/free of clutter Smoke alarms present/working

5. Bedroom Safety

Clear path to bed Nightstand accessible Cords secured/out of walkway

Notes / Recommendations

Evaluator Signature