Home & Personal
Safety Checklist
Objective: The checklist is designed for use in assessing any OH&S concerns in
an individual’s support. Comments should be written, and used in review for people
receiving service and staff. (See over for Personal Care & Sleepover Checklist)
Client Name
Date
____/_____/_____
Client Address
Support Required
Community Access:
Y
N
In home Respite:
Y
N
Personal Care
Y
N
Sleepover:
Y
N
Comments
Action
Is any Manual Handling required?
Manual Hoist
Y
N
Overhead Hoist
Y
N
Slide Transfer
Y
N
Assessment
available?
Y
N
Is medication required during
support?
Webster pack
Y
N
P.R.N.
Y
N
Current treatment
sheet available?
Y
N
Is transport required?
Y
N
Is a harness required? Y
N
Is a buckle guard
required
Y
N
Other concerns?
Y
N
Are there BOC?
Y
N
BSP available?
Y
N
Are there emergency
contacts available?
Y
N
Assessment Conducted by:
_________________________________________________________
Version 1
14/02/2012
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Home & Personal
Safety Checklist
Personal Care & Sleepover Checklist
Client Name
Date
____/_____/_____
Client Address
Support Required
In home Respite:
Y
N
Personal Care
Y
N
Sleepover:
Y
N
Comments
Action
Is any Manual Handling required?
Manual Hoist
Y
N
Overhead Hoist
Y
N
Slide Transfer
Y
N
Shower Chair?
Y
N
Other (pls specify)
Y
N
Assessment
available?
Y
N
Is medication required during
support?
Webster pack
Y
N
P.R.N.
Y
N
Current treatment
sheet available?
Y
N
Meal Preparation?
Y
N
Assistance Required?
Y
N
Peg Feeding?
Y
N
Other Concerns?
Y
N
Are there BOC?
Y
N
BSP available?
Y
N
Are there emergency
contacts available?
Y
N
Dietary requirements:
(Pls specify)
Assessment Conducted by:
________________________________________________________
Version 1
14/02/2012
Page 2 of 2