A Home Environmental Assessment Page 3
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1
2
3
4Problems
Yes, No, N/A
Potential Solutions
Solutions Agreed To:
Action By:
Comments:
Bathroom
Use non-skid backing to secure mats; or
Presence of unsecure bath mats
Y
N N/A
remove them
Carpet folds or frayed carpet
Y
N N/A
Tack down loose carpet
Pathways not clear: small objects, cords, papers,
Y
N N/A
Clean up clutter; or move objects
books in way of foot traffic
Lighting dim or inadequate
Y
N N/A
Provide better, brighter lighting
Absence of grab bars for toilet (not towel rack)
Y
N N/A
Install grab bars for toilet
Absence of grab bars for tub or shower
Install grab bars for tub or shower
Y
N N/A
Absence of hand held shower
Y
N N/A
Install hand held shower
Absence of bath bench
Y
N N/A
Need bath bench
Presence of toilet seat that is too low
Y
N N/A
Need raised toilet seat
Use rubber mat or non-skid strips for
Presence of slippery surfaces in tub or shower
Y
N N/A
tub/shower
Bedrooms
Use double-sided carpet tape on secure
Loose throw rugs, runners, or mats
Y
N N/A
rugs; or remove them
Carpet folds or frayed carpet
Tack down loose carpet
Y
N N/A
Pathways not clear: small objects, cords, papers,
Y
N N/A
Clean up clutter; or move objects
books in way of foot traffic
Lighting dim or inadequate
Y
N N/A
Provide better, brighter lighting
Absence of light switch within reach of the bed
Place lamps within reach of the bed
Y
N N/A
Absence of nightlight between bed and toilet
Y
N N/A
Install nightlight
Absence of easily accessible phone near bed
Y
N N/A
Move phone to more accessible location
Bed is of inappropriate height/firmness
Y
N N/A
Need bed of adequate height and firmness
Other (e.g., garage, backyard)
specify:_______________________________
Y
N N/A
specify:_______________________________
Y
N N/A
specify:_______________________________
Y
N N/A
specify:_______________________________
Y
N N/A
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