Thallon Community Care Service
[Agency Name]
Workplace Health and Safety
Checklist
Client Name:
Address:
Section One
Visibly Visibly Action
Safe Unsafe
Exterior of Home:
Front Steps ? ?
Back Steps ? ?
Ramps ? ?
Paths ? ?
Gates ? ?
Length of Grass ? ?
Outdoor Work:
Access to Clothes Line ? ?
Clothes Line ? ?
Pets:
Dog ? ?
Cat ? ?
Other: ? ?
Section Two
Visibly Visibly Action
Safe Unsafe
Inside Residence:
Floor Surfaces ? ?
Power Points ? ?
Ventilation ? ?
Lighting ? ?
Adequate space to
Manoeuvre equipment ? ?
Fire Hazards
E.g.: excess papers, cartons
Clear exits, etc ? ?
Bathroom:
Electrical Equipment
E.g. leads on floor or
Heaters in bathroom ? ?
Access to shower / bath
E.g.: awkward to clean ? ?
Laundry:
Location of Washing
Machine ? ?
Location of Laundry
E.g.: stairs etc ? ?
Power leads
E.g.: on ground, water
on ground ? ?
Section Three
Visibly Visibly Not Action
Safe Unsafe Available
Equipment:
Vacuum Cleaner ? ? ?
Carpet Sweeper ? ? ?
Broom ? ? ?
Mop Bucket ? ? ?
Mop – technical
wringing (no hand
wringing) ? ? ?
Washing Machine Type ? ? ?
Auto ?
Semi ?
Twin tub ?
Iron ? ? ?
Ironing Board ? ? ?
Hot water service ? ? ?
Cleaning fluids ? ? ?
Stove ? ?? ?
Food preparation
facilities ? ? ?
Section Four
Yes Possibly Action
Client and Family:
Is there any evidence of a
risk of a physical assault? ? ?
Is there any evidence of a
risk of sexual harassment? ? ?
Is the situation especially
demanding emotionally? ? ?
Is there evidence of a risk
of infectious disease? ? ?
Can the service be performed safely without any modifications to the residence or equipment and without any specific safe work instructions?
No ? (complete action below) Yes ?
Action
Signature: ___________________________________ Date: ___ / ___ / ___
(Coordinator – [Agency Name])
................
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