Site_Risk_Assessment_CDM_Form

Client Site Risk Assessment for Home Visits
Type:	Pre-Visit Assessment	On Site Assessment
Source:
Site Description: Location Type:
Name:
Address:
Emergency Contact Name and Number:

Violence
No Change
History of Violence/Agression/Abuse Yes No Not Known
Firearms/Weapons Yes No Not Known
Client Unreceptiveness/Behaviour Issues Yes No Not Known
Family/Other Occ. Unreceptiveness/Behaviour Yes No Not Known
Substance Use Yes No Not Known
Comments:
Control Plan (to be filled out if any risk is answered yes: Risk and Plan)


Occupational Health
No Change
Infectious/Communicable Disease Yes No Not Known
Hazardous Drugs Yes No Not Known
Blood and Body Fluids/Biohazards Yes No Not Known
Infestation Yes No Not Known
Sanitation Yes No Not Known
Comments:
Control Plan (to be filled out if any risk is answered yes: Risk and Plan)

Environmental
No Change
Site Access Yes No Not Known
Phone Access Yes No Not Known
Pets/Animals Yes No Not Known
Smoking Yes No Not Known
Oxygen Yes No Not Known
Work Space Hazards Yes No Not Known
Comments:
Control Plan (to be filled out if any risk is answered yes: Risk and Plan)


Muskuloskeletal
No Change
Client Mobility Yes No Not Known
Ergonomics Yes No Not Known
Comments:
Control Plan (to be filled out if any risk is answered yes: Risk and Plan)


Other Identified Risks
No Change
Other Yes No Not Known
Comments:
Control Plan (to be filled out if any risk is answered yes: Risk and Plan)

Restrictions
No Change
Community Health Employee
Pairs (Buddy) Yes No Not Known
Security Escort Yes No Not Known
Police Escort Yes No Not Known

Visits

Clinic Only - No Home Visits Yes No Not Known
Daytime Visits Only Yes No Not Known


Services Withdrawn Yes No Date:
Reason
Services Deferred Yes No Date:
Reason
Comments:


Other Occupant Details
No Change
Number of other occupants (excluding client)
Relationships
Comments:

Subject: