American College Of Surgeons - Inspiring Quality: Highest Standards, Better Outcomes

Prehospital Home Safety Checklist

This survey is provided as an educational service and is not intended to be exhaustive or certify a residence as safe or unsafe. We advise occupants to seek additional information if questions arise.

OK Needs Improvement
Bathroom
Non-skid mats or decals in tub

checkbox checkbox
Stairs (inside and outdoors)
Well-lit checkbox checkbox
Sturdy handrail along length of stairs

checkbox checkbox
Bedroom
Phone next to bed (may be by report)

checkbox checkbox
General
Secure carpeting on floors and staircases

checkbox checkbox
Fire Safety
Smoke detector functional checkbox checkbox
Fire extinguisher (in kitchen or nearby)

checkbox checkbox
Child Safety (if applicable)
Plastic plugs in unused electrical outlets checkbox checkbox
Cleaners out of reach or in locked cabinets checkbox checkbox
Medicines out of reach or in locked cabinets checkbox checkbox
Child safety gates installed around hazards checkbox checkbox