Social Service Home Visit Form

Social Service Home Visit Form (#64)

Social Worker Name:

Last Name

Case Name:

First Name

Last Name

Case Worker:

First Name

Last Name

Case Type:

Date & Time of Visit:

Check all that apply:

The home appears to be clean, safe, sanitary and in good repair

Waste is stored, located and disposed of in a manner that will not permit the transmission of communicable disease or odors, create a nuisance, or provide a breeding place or food source for insects or rodents

At least one toilet, bath or shower with hot and cold running water

An operable heating system

Suitable sleeping areas – no halls, stairways, unfinished attic, garage, bathroom, eating area, closet, shed, or detached buildings

Children of the opposite sex who are 5 or older do not share the same bedroom

Each child is provided with a clean, comfortable mattress, clean linens, blankets and a pillow

Medication and toxic substances are locked up so that children in the home cannot access

Operable telephone

Emergency telephone numbers – including fire, police, poison control and ambulance must be conspicuously posted adjacent to all telephones

Fireplaces, fireplace inserts, wood and coal burning stoves and free standing space heaters, if allowed by local ordinance, shall be installed equipped and operated according to manufacturer’s specification and requirements specified by local ordinance

Smoke detector on each level of residence (including basement)

Fire extinguisher gauge or button ensures adequate pressure. If there is not gauge or button, the extinguisher is tested and tagged by fire company or appropriate source

Protective caps in all electrical outlets (children under 5)

No exposed electrical wires

Guns locked and ammunition stored separately

Number of persons transported does not exceed vehicle capacity

Seat belts in automobiles are used by occupants

Children who are under eight (8) years of age who are transported in motor vehicles shall be securely fastened in a child passenger restraint system

Children shall be limited to floor level not more than 2 stories above ground level

Exits for building with up to and including 2 stories, a minimum of one exit from each floor kept free from obstructions shall be provided

First Aid supplies in the home

Fire escape plans are posted

Baby gates are used on staircases if they are under 2 years old

Smoke Alarms Operable?

Yes

Date Checked

Items Discussed During Visit:

Notes & Comments:

Today's Date:

I certify that this home meets the standards for approval as described in this form.

Social Service Home Visit Form

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