MCESFPN Check for Safety Home Safety Assessment Survey

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* 9. How did you hear about Check for Safety (CFS) home safety assessment?

CFS Flyer

Senior Center

Bingocize/Matter of Balance Workshop

Other (please specify)

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* 10. In the past 6 month, have you fallen in or around your home?

Yes

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* 11. If answered yes, have you limited any activities based on your fall?

Yes

N/A

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* 12. Pathways/Entrance to home (door used most often to access home)

Unable to complete. **Use comment section below to explain. **Make sure to check N/A for all questions in this section.

N/A

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* 13. Objects blocking entrance/pathway?

Yes

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* 14. Walkway free of cracks and holes?

Yes

N/A

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* 15. Outdoor lighting at entranceway?

Yes

N/A

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* 16. Handrails are on both sides of stairs and are well maintained.

Yes

N/A

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* 17. Ramp to access the residence

Yes

N/A

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* 18. Recommendations?

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* 19. HALLWAYS

Unable to complete **Use comment section below to explain. **Make sure to check N/A for all questions in this section.

N/A

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* 20. Loose throw rugs, runners, mats, etc.

Yes

None of the above

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* 21. Carpet that is frayed or doesn't lie flat?

Yes

None of the above

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* 22. Pathways clear of small objects, extension cords, clutter

Yes

N/A

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* 23. Lighting is dim or inadequate

Yes

N/A

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* 24. Any recommendations?

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* 25. Living Room/ Family Room

Unable to complete. **Use comment section below to explain. **Make sure to check N/A for all questions in this section.

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* 26. Loose throw rugs, runners, or mats, etc.

Yes

N/A

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* 27. Carpet that is frayed or does not lie flat?

Yes

N/A

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* 28. Pathways clear of small objects, extension cords, papers, etc.?

Yes

N/A

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* 29. Lighting is dim or inadequate?

Yes

N/A

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* 30. Telephone easily accessible?

Yes

N/A

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* 31. Chairs have solid armrests?

Yes

N/A

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* 32. Any recommendations?

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* 33. KITCHEN

Unable to complete. **Use comment section below to explain. **Make sure to check N/A for all questions in this section.

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* 34. Loose throw rugs, runners or mats?

Yes

N/A

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* 35. Pathways clear of small objects, extension cords, papers, etc.?

Yes

N/A

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* 36. Lighting is dim or inadequate?

Yes

N/A

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* 37. Items can be reached easily?

Yes

N/A

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* 38. Sturdy step stool in good repair?

Yes

N/A

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* 39. Telephone easily accessible?

Yes

N/A

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* 40. Any recommendations?

Coil and secure wires next to wall to eliminate trip hazards

If needed, use a multi outlet surge protector or have an electrician install another outlet.

Store things you use frequently on lower shelves or in drawers you can reach easily.

If you must use a step stool, get one with a side rail to hold onto. Never use a chair as a step stool.

Not at this time.

Other (please specify)

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* 41. BATHROOM

Could not complete. **Use comment section below to explain. **Make sure to check N/A for all questions in this section.

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* 42. Flooring has non-slip surface or rug with non-skid backing?

Yes

N/A

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* 43. Shower or tub has non-skid surface, mat, decals or abrasive surface?

Yes

N/A

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* 44. Shower or tub with sturdy grab-bar (not a towel rack)?

Yes

N/A

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* 45. Toilet seat height too low?

Yes

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* 46. Any recommendations?

Put a non-slip mat or self-stick strips on the bathtub/shower floor

Have grab bars installed next to and inside the tub, and next to the toilet

Not at this time.

Other (please specify)

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* 47. BEDROOMS

Could not complete. **Use comment section below to explain. **Make sure to check N/A for all questions in this section.

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* 48. Pathways clear of small objects, extension cords, papers, etc.?

Yes

N/A

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* 49. Light switch can be turned on before entering room?

Yes

N/A

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* 50. Lamp or light switch within reach of bed?

Yes

N/A

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* 51. Nightlight between bedroom and bathroom?

Yes

N/A

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* 52. Phone easily accessible at bedside.

Yes

N/A

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* 53. Any recommendations?

Coil or tape cords and wires next to the wall so you can’t trip over them.

If needed, use a multi outlet surge protector or have an electrician put in another outlet.

Place a lamp close to the bed where it’s easy to reach.

Put in a nightlight so you can see where you’re walking. Some nightlights go on by themselves after dark.

Add in a working flashlight for emergencies.

Not at this time.

Other recommendations?

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* 54. INDOOR STAIRS AND STEPS

Unable to complete. **Use comment section below to explain. **Make sure to check N/A for all questions in this section.

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* 55. Loose throw rugs, runners or mats?

Yes

N/A

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* 56. Carpet that is frayed and doesn’t lie flat?

Yes

N/A

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* 57. Pathways are clear of small objects, extension cords, clutter, etc.?

Yes

N/A

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* 58. Lighting is dim or inadequate (i.e. can’t see the outline of each step when descending)?

Yes

N/A

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* 59. Light switches at top and bottom of stairs?

Yes

N/A

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* 60. Broken/worn steps or coverings?

Yes

N/A

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* 61. Full-length handrails on both sides of stairs

Yes

N/A

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* 62. Steps and edges are clearly visible?

Yes

N/A

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* 63. Any recommendations?

Make sure the carpet is firmly attached to every step, or remove the carpet and attach non-slip rubber treads to the stairs.

Always keep objects off stairs.

Increase lighting in order to see the outline of each step when descending.

Have an electrician put in an overhead light and light switch at the top and bottom of the stairs.

Purchase battery operated light switches.

Fix loose handrails or replace with new ones.

Make sure handrails are on both sides of the stairs and are as long as the stairs.

Not at this time.

Other recommendations? (please specify)

MCESFPN Check for Safety Home Safety Assessment

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* 1. Resident's first and last name

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* 2. Date

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* 3. Street address

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* 4. City/State/Zip Code

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* 5. Cell phone # (or landline if cell is not available)

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* 6. Email address

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* 7. Fall Prevention Team Members

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* 8. Assessment start time

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* 9. How did you hear about Check for Safety (CFS) home safety assessment?

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* 10. In the past 6 month, have you fallen in or around your home?

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* 11. If answered yes, have you limited any activities based on your fall?

Question Title

* 12. Pathways/Entrance to home (door used most often to access home)

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* 13. Objects blocking entrance/pathway?

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* 14. Walkway free of cracks and holes?

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* 15. Outdoor lighting at entranceway?

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* 16. Handrails are on both sides of stairs and are well maintained.

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* 17. Ramp to access the residence

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* 18. Recommendations?

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* 19. HALLWAYS

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* 20. Loose throw rugs, runners, mats, etc.

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* 21. Carpet that is frayed or doesn't lie flat?

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* 22. Pathways clear of small objects, extension cords, clutter

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* 23. Lighting is dim or inadequate

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* 24. Any recommendations?

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* 25. Living Room/ Family Room

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* 26. Loose throw rugs, runners, or mats, etc.

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* 27. Carpet that is frayed or does not lie flat?

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* 28. Pathways clear of small objects, extension cords, papers, etc.?

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* 29. Lighting is dim or inadequate?

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* 30. Telephone easily accessible?

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* 31. Chairs have solid armrests?

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* 32. Any recommendations?

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* 33. KITCHEN

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* 34. Loose throw rugs, runners or mats?

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* 35. Pathways clear of small objects, extension cords, papers, etc.?

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* 36. Lighting is dim or inadequate?

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* 37. Items can be reached easily?

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* 38. Sturdy step stool in good repair?

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* 39. Telephone easily accessible?

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