SAFETY ASSESSMENT FORM TOOL – HAZARD IDENTIFICATION

Client Health Record #
Client Surname
Given Name
Community Health Services
SAFETY ASSESSMENT FORM TOOL –
HAZARD IDENTIFICATION
Date of Birth
Gender
MFRN
PHIN
The purpose of the Safety Assessment Form Tool (SAFT) is to help you to identify hazards associated with all aspects of the client
visit. The SAFT will take you through the five hazard categories and will help you to identify hazards when you are assessing the
client’s home and environment. The layout of the SAFT is user friendly and will allow you to quickly scan the hazard categories,
check tick boxes for applicable hazards, and quickly move on to a different category if there are no hazards to be identified.
The next step after completing the SAFT is to create a Safe Visit Plan (SVP). Each identified hazard should be addressed in the
SVP. The SVP needs to provide guidance to employees on how to deal with the hazard so that the harmful effects of the hazard
are eliminated or minimized. We have provided some options for you to consider when you are creating the SVP. The SVP is a
tool that has been created to help you to find ways of dealing with the identified hazards, but also please feel free to create your
own safe work prevention plans as necessary.
If severe hazards are identified that cannot be managed immediately, the SVP might not be the best option and alternative ways for
providing care to the client should be considered while a SVP is being developed. These alternate options are also provided at the
end of this document.
After the SAFT and the SVP are completed, please pass them on to the appropriate care providers. We have also provided you
with some communication plan options which will allow you to indicate who needs to receive the SAFT, the SVP, or both.
Please contact WRHA Occupational and Environmental Safety & Health (OESH) at 837-0866 or FSCA Safety and Health
Unit (SHU) at 945-1610 regarding any questions, concerns, or if assistance is needed regarding the identification of hazards,
completion of the SAFT, and the development of the SVP.
Date of Initial Safety Assessment:
Completed by:
Central Office Phone Number:
D D M M M Y Y Y Y
NAME AND DESIGNATION
Identify type of location. Please select one of the following:
Single family
Multi-tenant (identify type below):
Duplex Hotel Shelter
Apartment building Supported Living
Rooming House Residential Care Facility
Non-residential setting (i.e. park, underpass, abandoned building,
public area).
Other. Please specify: ________________________________________________________
Section 1. Working Alone/Violence/Physical Hazards Assessment
Time of Visit(s)/Time of Service Delivery
Please check all that may apply.
A. During the regular working day
B. After Hours (evenings, overnight),
identify time:
C. Respite Visits to last 4 - 8 hours
D. Weekends and statutory holidays,
identify time:
E. Other. Please specify:
24 HOUR
24 HOUR
____________________________________________________________
Section 1. a. Hazards associated with getting to client’s home/site
Are the following hazards present?
Lengthy walk to client’s home. Please identify the concern(s):
Distance (excessive distance or staff member unable to walk the distance)
Time of day (evening, early morning). Indicate time of day when concern exists:
24 HOUR
Neighbourhood concerns or hazards in area.
Poorly lit parking lot/street (may be an issue if visit is in the evening and/or early morning)
Parking lot poorly maintained (e.g.: extensive cracks, pot holes, uneven pavement)
Client’s property (driveway, sidewalk, walkway, back lane) poorly maintained (e.g. extensive cracks, pot holes, uneven pavement)
Client’s property (driveway, sidewalk, walkway, back lane, parking lot) not routinely cleared, salted and/or sanded during winter months
Access to client’s home restricted, difficulty accessing client’s home (e.g. clutter, cars, construction in the way)
City sidewalk not well maintained (e.g. extensive cracks, pot holes, uneven pavement)
City sidewalk not well maintained during the winter months (e.g. extensive snow and ice)
Other. Please specify: ____________________________________________________________________________________________________________________________
None identified, please proceed to the next section.
FORM # W-00439 10/11 CHS Safety Assessment Form Tool – Hazard Identification Page 1 of 3

Client Health Record #
Client Surname
Given Name
Community Health Services
SAFETY ASSESSMENT FORM TOOL –
HAZARD IDENTIFICATION
Date of Birth
Gender
MFRN
PHIN
Section 1. Working Alone/Violence/Physical Hazards Assessment (continued)
Section 1. b. Reported/known/emerging site or neighborhood concerns.
Please identify the concerns
Gangs Solvent/alcohol/drug use, drug dealing/activity Weapons Observable street crime/history of crime
Other. Please specify: ___________________________________________________________________________________________________________________________
Are any of the above hazards impacted by the time of the day or day of the week? ................................................ No Yes
If yes, please indicate time of day:
24 HOUR
None identified, please proceed to the next section.
and Day of Week:
Section 1. c. Abusive and Violent Behaviour
Abusive or threatening behaviors that staff are exposed to:
By whom Client, Type of abuse: Physical Verbal
Family member, Relation to Client: _________________________ , Type of abuse: Physical Verbal
Associate: lives in home................................... Type of abuse: Physical Verbal
lives out of home............................. Type of abuse: Physical Verbal
Neighbours........................................................................ Type of abuse: Physical Verbal
None identified, please proceed to the next section.
Section 1. d. Hazards Inside Client’s Home/Apartment
Are the following hazards present in the home, check only those that are identified:
Exits/doors are blocked
Stairs poorly maintained, missing railing
Floors are cracked, loose rugs, loose mats
Cluttered work area affecting ability to perform tasks safely
Cramped (lack of space) work area affecting ability to perform tasks safely
Access to work area restricted or blocked
Electrical appliances, other equipment required to perform tasks in poor working order
Weapons (guns, knives) inside the home, visible and not safely stored
Phone not available
Other. Please specify: ___________________________________________________________________________________________________________________________
None identified, please proceed to the next section.
Section 1. e. Multi Tenant Dwellings Only
Please fill in this section only if applicable, check only hazards that are identified. If not, please proceed to next section.
Common stairs poorly maintained
Poorly lit hallway/stairwell
Common hallways are cluttered and full of debris
Exits and emergency exits are not visible or marked
Exits are blocked or non-functional
The elevator is non-functional/requires excessive stair climbing
A ‘buzzer’ system is not available/difficulty notifying client and entering building
The external door is locked during the day (cannot notify client or gain access to building)
There are no security cameras or a security guard on site/assistance not available in an emergency
Phone on site not available to staff/cannot call for help in an emergency
Other. Please specify: ___________________________________________________________________________________________________________________________
None identified, please proceed to the next section.
FORM # W-00439 10/11 CHS Safety Assessment Form Tool – Hazard Identification Page 2 of 3

Client Health Record #
Client Surname
Given Name
Community Health Services
SAFETY ASSESSMENT FORM TOOL –
HAZARD IDENTIFICATION
Date of Birth
Gender
MFRN
PHIN
Section 2. Biological Hazards
Section 2. a. Animals in the Home/Site
Animals in the home/site ........................................................................................................................................... No Yes
None identified, please proceed to the next section.
If yes, identify the following:
Type of animals: _______________________________________________________________________________________________________________________________________
How many of each type: ______________________________________________________________________________________________________________________________
Does the client follow guidelines regarding animals? ................................................................................................ No Yes
If no, the Safe Visit Plan should be developed
Section 2. b. Stray Needles (Sharps) in the Home/Site
There are a significant number of stray/improperly disposed used needles/sharps/lancets in the home/site
None identified, please proceed to the next section.
Section 2. c. Infestation in the Home/Site
Evidence of an infestation in the home/site
If yes, please indicate the type of infestation: mice rats roaches bed bugs mould
Other Biological Hazards. Please specify: ________________________________________________________________________________________________________
None identified, please proceed to the next section.
Section 3. Chemical Hazards
Section 3. a. Smoking in the Home/Site
Client/Household member(s) smoke in the home/site.
Client/Household member(s) do not follow the WRHA non-smoking policy regarding cigarettes and marijuana.
If box is checked, a Safe Visit Plan needs to be developed.
Other chemical hazards. Please specify: _________________________________________________________________________________________________________
None identified. Please proceed to next section.
Musculoskeletal Injury Prevention/Ergonomics
Ergonomic hazards for Manual Materials Handling (laundry, food prep, housekeeping) and Safe Patient Handling (HCA, wound
care, etc.) can be dealt with via those specific processes. Should either of those services be required, please refer to their specific
assessment processes and address the applicable hazards accordingly.
SAFT
Completed by:
NAME AND DESIGNATION
SAFT Reviewed
and/or Updated by:
NAME AND DESIGNATION
Date:
D D M M M Y Y Y Y
Date:
D D M M M Y Y Y Y
SVP Completed: Yes No
SVP Updated: Yes No
FORM # W-00439 10/11 CHS Safety Assessment Form Tool – Hazard Identification Page 3 of 3