Home Safety WelcomeHousehold Responsibilities Assessment An online form for completing an assessment of client's ability to carry out household responsibilities.The evaluator uses his phone, tablet or computer to fill in answers to questions about how the client functions safely and efficiently at home.The evaluator can then email the report to review or print the summary later.You begin by first filling in the client info below - then use the "Previous" and "Next" buttons to continue with the rest of the assessment.Client InfoClient InfoClient NameDateLives AloneYesNoAt Risk for Falls?YesNoHousehold ResponsibilitiesCold food prepHot food prepManaging medsFinancesManaging householdMeal planningObtaining groceriesUsing Electronic Devices LaundryPet CareExtra InfoEmergency ReadinessEmergency PreparednessEmergency ReadinessSmoke detectorFire extinguisherCarbon monoxide detectorPoison control numberEmergency contactCall 911First aid suppliesElectrical panelFalls PreventionFalls PreventionFalls Reduction AwarenessUses prescribed AERemoves obstacles in pathEliminates throw rugsHas adequate lightingMonitors medsMonitors alcohol Monitor petsUsing PhoneDial personal contactsDial 911Dial medical officesDial pharmacy Charge phoneControl volumeUse cameraUsing PhoneUsing PhonePreparing Cold FoodsSlicing foodsCutting foodsPour liquidsCooking Hot FoodsCooking Hot Foods Med ManagementMed ManagementPill OrganizationPills up to dateAccurately placed in sorterUses medication schedule/chartPurpose of MedsMeal PlanningExpired foodsFood on handShopping listSpoiled foodObtaining GroceriesCarry foods into homeStock food on shelfStock food in refrigeratorAppliances Used?MicrowaveStovetopToasterOvenSlow cookerToaster ovenCan openerFinanceFinanceMoney TasksPay bills on timeWrite checkBalance checkbookBudgetOnline bankingManage passwordsHousehold ManagementHousehold ManagementMethods for Managing HouseholdCalendarNotebook Phone calendarPhone remindersUse smart speakerShopping list for household suppliesMeal PlanningMeal PlanningUsing Electronic DevicesUsing Electronic DevicesManaging DevicesLandlineSmartphoneCharge phoneLogin to tabletCharge tabletLogin to computerLaundryLaundryManaging LaundryMeasure amountsOperate washerCarry laundry in homeOperate dryerPet CareFinancePet CareStock foodFill water on timeFeed on timeLet pet outsideClean up poopBatheGroomTake for walkSend Message