Rebuilding Together Greater Milwaukee
Occupational Therapy Home Safety Assessment
This document is for RTGM use only and is not to be reproduced or altered without
the permission of Linda Balfanz, OTR
Applicant Name(s):
Address:
City:
OT
Telephone:
Telephone:
State:
Date:
Cell:
Zip:
Homeowner health condition / Biography
Ambulation Device:
Homeowner Health Assessment Interview
Health Condition
Good
Fair
Poor
Recent:
General Eye sight:
Good
Fair
Poor
Illness
Surgery
Other:
Uses Hearing Aid
Yes
No
Last Doctor / Eye Visit:
Doc
Eye
Outside The House
Type of home:
Number of Steps:
Step Height:
Are Steps Even?
Condition:
One Story
Front:
Front:
Yes
No
One and a-half story
Back:
Back:
Yes
No
Two Story
Side:
Side:
Yes
No
Good
Needs Repairs
Good
Needs Repairs
Good
Needs Repairs
Number of Railings:
Railing Height:
Are Railings Secured?
Front:
Front:
Yes
No
Back:
Back:
Yes
No
Side:
Side:
Yes
No
Condition:
Good
Poor
Good
Poor
Good
Poor
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Rebuilding Together Greater Milwaukee
Occupational Therapy Home Safety Assessment
Outside The House (continued)
Front:
Back:
Wheel Chair Accessible?
Yes
No
Yes
Porch or Stoop support Wheel Chair Turning Space?
Yes
No
Yes
Yes
No
Yes
Future Need?
Explain:
Front:
Back:
Outside Light:
No
Side:
Yes
No
No
No
Yes
Yes
No
No
Door Width:
Condition:
Not Working
Adequate
Needs Repairs
Side:
Not Working
Adequate
Not Working
Needs Repairs
Adequate
Needs Repairs
1. Do you have difficulty walking/entering into the house?
Describe:
Yes
No
2. Do you have difficulty identifying visitors?
Window in door
Yes
No
Describe:
Yes
Yes
No
No
Peephole in door
3. Do you have difficulty hearing the doorbell or knocks on the door?
Yes
No
Door bell Working? Yes
No | Door bell Installed
Yes
No | Knocker Installed
Yes
No
Describe:
4. Do you have difficulty managing the door locks and knobs/handles?
Yes
Door locks working?
Yes
No | knobs Installed
Yes
No | lever handle Installed
Describe:
5. Do you have difficulty getting the mail safely?
Location of Mailbox
Too High
Too Low
Describe:
6. Do you ever use a
wheelchair,
walker,
cane,
Opposite of Door swing
other:
No
Yes
No
Yes
No
Slot in Door
outside the home?
Yes
No
Yes
Yes
No
No
Describe:
7. Do you have difficulty getting trash to the carts?
Do you have difficulty getting carts to the Collection Point?
Describe:
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©RTGM 2010
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Rebuilding Together Greater Milwaukee
Occupational Therapy Home Safety Assessment
This document is for RTGM use only and is not to be reproduced or altered without
the permission of Linda Balfanz, OTR
81926586
©RTGM 2010
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Rebuilding Together Greater Milwaukee
Occupational Therapy Home Safety Assessment
Inside The House-General
1. Do you use throw rugs?
Kitchen:
Backed
Not Backed
Condition:
Fringe Ends
Curling
Yes
Bathroom:
Backed
Not Backed
Moves Easily
Good
2. Do you ever trip inside the home?
Yes
No Have you fallen inside the home?
Location: Bedroom Kitchen Bathroom Living Room Dining Room
Have you fallen outside the home?
Location:
3. In what rooms are you most concerned about falling?
Location: Bedroom Kitchen Bathroom Living Room
4. Your telephone, can you easily?
Number of Cordless Phones:
Location:
Bedroom
Kitchen
No
Hallway
Stair
reach | Yes
No |
Telephone
Emergency numbers kept?
Other:
Bathroom Living Room Dining Room Hallway
Stair
read the dial |
5. Do you have nightlights?
Location: Bedroom Kitchen Bathroom
Do you keep lights on at night?
Location: Bedroom Kitchen Bathroom
Adequacy:
Good
Fair
Poor
6. Observe: pathways free of obstacles/clutter?
Loose/frayed carpet?
Yes
No
Location: Bedroom Kitchen Bathroom
Yes
No |
Living Room
Dining Room
Living Room
Dining Room
Yes
No
Hallway Stair
Yes
No
Hallway Stair
Is a Trip Hazard?
Living Room Dining Room
Yes
No
Yes
No
Hallway Stair
7. Observe: does homeowner furniture walk?
8. How many stairs are inside the home?
Stair Height:
Number of Hand railings:
Dining Room
Yes
No
Hallway Stair
Yes
No
Yes
To Basement:
To Basement:
To Basement:
9. Light switch at the top and bottom of the stairs?
Yes
No
To 2nd Floor:
To 2nd Floor:
To 2nd Floor:
No Is the lighting adequate?
Yes
No
10. Additional comments:
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Rebuilding Together Greater Milwaukee
Occupational Therapy Home Safety Assessment
Living Room / Dining Room
1. Do you have any difficulty using a
Do you have a favorite chair?
Have risers been installed?
Yes
Observe Accessibility:
sofa? |
Yes
No
No |
No
Yes
Would benefit from risers?
Yes
No
No
Yes
No
2. Do you have a remote control for your Television?
3. Can you easily |
blinds
Yes
chair? |
Yes
reach window(s)
Yes
No | operate window(s)
Yes
No | operate
No | operate shades
Yes
No | draw cord
Yes
No | at window(s)?
4. Observe: are there any obstructions in the walking paths?
Describe:
Yes
No
5. Observe: is the lighting adequate?
Would benefit from | brighter lighting?
Yes
Yes
No
No
6. Other:
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Rebuilding Together Greater Milwaukee
Occupational Therapy Home Safety Assessment
Kitchen
1. Do you have difficulty reaching/using cupboards or storage space?
Would benefit from Additional Storage?
Would benefit with a Reacher?
Describe:
Yes
Yes
Yes
No
No
No
2. Do you have difficulty lifting/transporting items during meal preparation?
Describe:
Yes
No
3. Can you easily open/close drawers/cabinet doors?
Type of Pull:
Handle
Knob
Other:
Describe:
Yes
No
4. Do you have any difficulty working at the sink/counter or using the faucets?
Describe:
Yes
No
5. Do you have any difficulty using the stove/microwave?
Are controls easy to see/read at off position
Describe:
Yes
Yes
No
No
6. Is there a fire extinguisher/baking soda accessible at stove in case of fire?
Fire Extinguisher?
Yes
No
Baking Soda?
Yes
Yes
No
No
7. Can you easily open/close, and get items in/out of the refrigerator?
Is door swing correct for location?
Yes
Yes
No
No
8. Do you get tired easily while making meals?
Yes
No
9. Observe: is the lighting adequate?
Would benefit from | brighter lighting?
Yes
Yes
No
No
10. Other:
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Rebuilding Together Greater Milwaukee
Occupational Therapy Home Safety Assessment
Bedroom #1
1. Can you easily get into and out of the bed?
Would benefit from Risers?
Describe:
Yes
Yes
No
No
2. Can you easily move around the bedroom?
Are there any obstructions in the walking paths
Describe:
Yes
Yes
No
No
3. Can you easily reach clothing, coats, shoes/other closet items?
Would benefit with additional storage, or lower closet rod?
Describe:
Yes
Yes
No
No
4. Can you easily reach, open and close all dresser drawers?
Describe:
Yes
No
5. Can you easily reach a | light
Yes
No | telephone Yes
No | from your bed?
Would benefit with wireless devices (i.e. remote lights or remote phone)?
Yes
No
Describe:
6. Observe/Measure: Door entrance width:
Light switch location adequate?
Telephone location adequate?
Would benefit from swing clear hinges?
Describe:
Would benefit from wider door?
7. Observe: is the lighting adequate?
Would benefit from | brighter lighting?
Yes
Yes
Yes
Yes
No
No
No
No
Yes
Yes
No
No
8. Other:
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Rebuilding Together Greater Milwaukee
Occupational Therapy Home Safety Assessment
Bedroom #2
1. Can you easily get into and out of the bed?
Would benefit from Risers?
Describe:
Yes
Yes
No
No
2. Can you easily move around the bedroom?
Are there any obstructions in the walking paths
Describe:
Yes
Yes
No
No
3. Can you easily reach clothing, coats, shoes/other closet items?
Would benefit with additional storage, or lower closet rod?
Describe:
Yes
Yes
No
No
4. Can you easily reach, open and close all dresser drawers?
Describe:
Yes
No
5. Can you easily reach a | light
Yes
No | telephone Yes
No | from your bed?
Would benefit with wireless devices (i.e. remote lights or remote phone)?
Yes
No
Describe:
6. Observe/Measure: Door entrance width:
Light switch location adequate?
Telephone location adequate?
Would benefit from swing clear hinges?
Describe:
Would benefit from wider door?
7. Observe: is the lighting adequate?
Would benefit from | brighter lighting?
Yes
Yes
Yes
Yes
No
No
No
No
Yes
Yes
No
No
8. Other:
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Rebuilding Together Greater Milwaukee
Occupational Therapy Home Safety Assessment
Bathroom
1. Do you have any difficulty using the | faucet?
Replace faucet?
Would benefit from | single handle faucet?
Yes
Describe:
Yes
No
Yes
No
lever handled faucet?
Yes
No
No |
Yes
No
3. Do you have difficulty stepping into/out of the bath/shower?
Describe:
Yes
No
4. Observe: are there non-slip mats/strips in the tub/shower?
non-slip mats
non-slip strips
Yes
No
5. Do you have any difficulty taking a bath or a shower?
Describe:
Yes
No
2. Do you have any difficulty using or storing personal care items near the sink/tub/shower?
Describe:
6. Do you have any difficulty using the
drain stopper | Yes No
tub faucets | Yes
Do they work?
Describe:
tub faucets |
No |
Yes
shower control |
No |
Yes
shower control |
No |
Yes
drain stopper |
No
Yes
No
7. Do you have/use any of the following assistive equipment?
Tub Chair
Have
Use
Tub Bench
Have
Use
Reacher
Have
Use
Sock aider
Have
Use
Hand Held Shower
Have
Use
Grab Bars
Have
Use
Long Handle Sponge
Have
Use
Other
Raised Toilet Seat
Have
Use
Bedside Commode
Have
Use
Long Handle Shoehorn
Have
Use
Other
8. Do you have any difficulty getting on/off the toilet?
Type:
Older low toilet
Newer high toilet
Describe:
Yes
No
9. Do you have any difficulty reaching the toilet paper?
Describe:
Yes
No
10. Observe: is the lighting adequate?
Would benefit from | brighter lighting?
Yes
Yes
No
No
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©RTGM 2010
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Rebuilding Together Greater Milwaukee
Occupational Therapy Home Safety Assessment
Bathroom (continued)
11. Observe/Measure: Door entrance width:
Light switch location adequate?
Telephone location adequate?
Would benefit from swing clear hinges?
Describe:
Would benefit from wider door?
Yes
Yes
Yes
Yes
No
No
No
No
12. Other:
Basement / Laundry Room
1. How do you transport your laundry to the washer?
Describe:
Bin with wheels
Hand Basket
Laundry Bag
2. How do you transport your laundry to the dryer?
Bin with wheels
Hand Basket
Laundry Bag
Directly by hand from the Washer
Describe:
3. Do you have any difficulty using or seeing the dials on the washer/dryer?
Describe:
Yes
No
Yes
No
5. Is washer/dryer near stair location?
Describe:
Is laundry chute near washer/dryer?
Describe:
Yes
No
Yes
No
6. Observe: is the lighting adequate?
Would benefit from | brighter lighting?
Yes
Yes
No
No
4. If basement used:
See Stair / Hand Railings page 3 number 8
Is the area free of clutter?
Describe:
7. Other:
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Rebuilding Together Greater Milwaukee
Occupational Therapy Home Safety Assessment
Summary of Home Safety Assessment
Assistive Equipment Recommendations:
Homeowner Approval:
Yes
No
Signature:
Suggested Home Environment Changes:
Homeowner Approval:
Yes
No
Signature:
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Rebuilding Together Greater Milwaukee
Occupational Therapy Home Safety Assessment
OT Functional Home Safety Recommendations
Outside Home:

Inside Home General:

Living Room / Dining Room:

Kitchen:

Bedroom:

Bathroom:

Basement / Laundry Room:

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©RTGM 2010
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Rebuilding Together Greater Milwaukee
Occupational Therapy Home Safety Assessment
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