Home Safety Assessment Form
Score the hazards in a residence area by area, covering lighting, driveways, walkways, entry steps, hallways, bathrooms, kitchens and laundry spaces. Note fields capture anything that needs repair or follow-up. Built for occupational therapists, caregivers and assessors visiting a property.
Already have an account? Log in
Page 1
First Name
Last Name
Street Address
City
State / Province
ZIP / Postal Code
Page 2
| Column 1 | Column 2 | Column 3 | |
|---|---|---|---|
| Row 1 | |||
| Row 2 |
| Column 1 | Column 2 | Column 3 | |
|---|---|---|---|
| Row 1 | |||
| Row 2 |
| Column 1 | Column 2 | Column 3 | |
|---|---|---|---|
| Row 1 | |||
| Row 2 |
| Column 1 | Column 2 | Column 3 | |
|---|---|---|---|
| Row 1 | |||
| Row 2 |
| Column 1 | Column 2 | Column 3 | |
|---|---|---|---|
| Row 1 | |||
| Row 2 |
Page 3
| Column 1 | Column 2 | Column 3 | |
|---|---|---|---|
| Row 1 | |||
| Row 2 |
| Column 1 | Column 2 | Column 3 | |
|---|---|---|---|
| Row 1 | |||
| Row 2 |
| Column 1 | Column 2 | Column 3 | |
|---|---|---|---|
| Row 1 | |||
| Row 2 |
| Column 1 | Column 2 | Column 3 | |
|---|---|---|---|
| Row 1 | |||
| Row 2 |
| Column 1 | Column 2 | Column 3 | |
|---|---|---|---|
| Row 1 | |||
| Row 2 |
| Column 1 | Column 2 | Column 3 | |
|---|---|---|---|
| Row 1 | |||
| Row 2 |