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F-21 Safe Environment Checklist Form

F-21 Safe Environment Checklist Form

Safe Environment Checklist-Home

Hazard Inspection


Fire and smoke alarms
High-risk location (e.g. isolated or remote location, high rise flat)
Furniture and equipment are in good repair (check for broken seating, accessories, etc.).
Hardware in furniture/equipment is recessed and securely fastened
Furniture has no sharp edges at a level to injure the participant.
Presence of weapons in the home
External services for gardening, general maintenance
If pesticides are used, is information provided to workers for safe use
Hot water temperature checked (review state requirements)
Temperature control devices such as thermostatic mixing valves (TMV) or tempering valves control the output temperature of the water at the tap in situ


Medication stored on-premises
Medication in a locked cabinet
Should medication be in a locked cabinet?


Electrical cords on equipment and appliances are not frayed;
Cords are secured
No exposed wiring
Regular inspections are completed to re-assess electrical hazards


Smoker/smoking fumes
Chemicals used have ammonia or similar
Toxic gases or vapours
Other? (please specify)
control cleaning products used in participants' homes
Register of hazardous substances, including MSDS sheets no more than five years old?


Uneven, slippery or steep surfaces
Poor housekeeping
Obstacles being placed in the vicinity
Loose rugs, carpets
Inappropriate or poorly maintained floor or walking surfaces (i.e. lack of a slip-resistant surface, unprotected holes, penetrations or gaps?)
Stairs or ramps
Guardrails or other suitable edge protection


Transporting the participant equipment available
Carrying equipment required
Equipment available to move participants as needed
Repetitive or twisting body movement is limited
Frequent lifting of participant or equipment is required
Lifting or moving participant or equipment over long distances or up steps or stairs
Inadequate or poorly placed lighting while lifting or moving participant or equipment
Interference of the employee's clothing or personal protective equipment with manual handling performance


Known history of violence
Previous assaults/threats/verbal violence
A criminal record for violence or sexual assault
Reports from affiliated agencies/stakeholders
Use of firearms in the past
History of mental health issues
Substance abuse
The impact of the intervention causing stress or aggression in participant
The occurrence of any incident in the participant/family situation could increase the risk to the employee's safety
Indicators of violence,e.g. voice tone, mood swings, physical presentation/ behaviour
Unknown adults in the home
History of mental health issues
History of substance abuse
Security issues
Participant presenting in an escalating state of crisis


Employees informed the process in an emergency (e.g. mobile phones, duress alarms)?
Regular contact is maintained with workers to ensure safety and supervision
System to ensure knowledge of the location of all workers at all times during work shifts
Reporting mechanisms if any hazards


sharps procedure in place to manage the handling of sharps in participant's homes
Provided with adequate information on communicable diseases? (e.g. symptoms, long term health effects, risk factors and controls to minimise risk, including immunisation)
Trained in relevant policies and procedures
Trained in hazard and risk management
Trained in incident management
Trained in complaints and feedback procedures
Trained in universal infection control procedures
Trained in hot water safety risk management
Provide adequate PPE (e.g. range of gloves for both personal and domestic support workers),

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