Safety Checklist

Name

Date

Address

Phone

Email

I will adhere to the following standards:

I will not consume alcohol or any illegal substance in the presence of clients.

I will not abuse prescribed medications in the presence of clients and will take any prescription medications as prescribed by a professional only.

I will not consume nicotine products in my home or vehicle while a client is present.

I am free of any physical or mental conditions that would interfere with my ability to provide care.

My home and any other building on the property are in safe and good repair.

I have the following items out of a client’s reach or locked up:

Flammable or combustible materials

Plastic bags

Cleaning supplies, detergents, poisons, insecticides, etc.

Medications/drugs/alcohol

Matches, cigarette lighters, tobacco products, power tools

I will maintain protective covers on all electrical outlets not in use, when providing care for clientele under age seven.

I agree to keep all firearms or other dangerous weapons in the home unloaded and locked in an area inaccessible to clients.

All household pets will be vaccinated for rabies and other disease per local ordinances.

All children will be transported in insured vehicles only and will be properly restrained with an approved safety restraint or seat belt (per their age/weight requirements).

Furnaces, stoves, and flue pipes are kept away from combustibles.

Portable heaters are located and maintained properly (No Kerosene heaters are utilized in the home).

All clothes, curtains, and furniture are kept away from stoves, heaters, and fireplaces.

For wood burners and fireplaces, the chimney is cleaned and checked regularly.

The furnace is inspected regularly by a fire professional.

Flammable liquids stored in approved safety cans.

Windows in sleeping areas capable of being opened.

Extension cords placed safely and used on a temporarily-only basis.

Surge protectors are being used safely and effectively.

Fire evacuation plan will be discussed/practiced with each client and there is an identified external meeting place.

The first floor and above have at least two unobstructed means of exit.

If basement bedrooms are utilized for overnight respite, there will be two unobstructed means of exit.

I will maintain the following items in my home:

A mounted fire extinguisher near the kitchen

A functioning smoke detector on every level and at head of every stairway

A functioning carbon monoxide detector on every level

Disclaimer and Signature

I certify that my answers are true and complete to the best of my knowledge.

Signature

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Thanks for submitting!

CONTACT US

For more information or if you have any inquiries, please do not hesitate to contact:

Green Lake, Portage, Waupaca, & Waushara Counties:

Matt Rohan (920) 250-0656

mentoring.mattrohan@gmail.com

Outagamie, Shawano & Calumet Counties:

Sarah Funk (920) 422-4220

mentoring.funk@gmail.com

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