Appendix D. Home Hazard Checklist Form_OAHM_FINAL_SPL

Appendix D

Home Hazard Checklist

Older Adults Home Modification Program

Home Hazard Checklist¹

(adapted from CDC’s Home Safety Checklist, CPSC’s Home Safety Checklist, PD&R 2011, Rebuilding Together Safe at Home Checklist)

Study ID			Visit		Today’s Date (mm/dd/yyyy)	Form Completed By:
Site ID	Field Team ID	Client ID				Name	Job Title
			☐ Baseline ☐ Follow-Up				(dropdown menu: OT, OTA, CAPS, other [Specify])

N.° de control de OMB 2528-XXXX, fecha de expiración XX/XX/2024. Este formulario fue diseñado para proporcionar al HUD información sobre la eficacia de su Programa de Subvenciones para Modificaciones de Hogares para Adultos Mayores. La información que proporcione es voluntaria. Su casa puede ser inscrita en el programa sin importar si usted decide participar o no. Se calcula que la carga de informes públicos para la recopilación de esta información es de 25 minutos por respuesta. Es posible que el HUD no recopile esta información y no es necesario que complete este formulario, a menos que muestre un número de control OMB válido actualmente.

Instructions: This home hazard checklist is designed to be completed by the OT but can be completed by other grantee staff. In general, answer questions based on your observations but ask the client if clarification is needed.

Suggested Script: “Gracias por reunirse conmigo hoy. Este cuestionario tomará unos 25 minutos. ¿Tiene alguna pregunta antes de que comencemos?”

GENERAL DWELLING QUESTIONS:

1. (baseline only) Ask the client if you don’t already know the answer: “¿Cuándo fue construida su casa?”

□ Antes de 1900

□ 1900-1920

□ 1921-1940

□ 1941-1960

□ 1961-1980

□ 1981-2000

□ 2001-2020

□ 2021-presente

□ Not answered/don’t know

2. (baseline only) Tipo de hogar/residencia principal:

□ Vivienda unifamiliar, una casa separada de cualquier otra

□ Vivienda unifamiliar, adosada a una o más viviendas (por ejemplo, casa tipo townhouse, en hilera, dúplex, triplex, cuadrúplex)

□ Condominio en edificio de unidades múltiples

□ Unidad en una cooperativa de vivienda

□ Casa prefabricada o móvil

□ Unidad de vivienda accesoria

□ Otro tipo no mencionado. Especificar ____________________

3. Cantidad de pisos dentro del hogar: _______________

GENERAL HOME INTERIOR (PD&R 2011, RT Safe at Home Checklist) For homes in multi-unit buildings, inspect only the unit itself, not common areas.

A.4. Does the home currently have any of the following features:	Yes, and is a hazard	Yes, but is not a hazard	No	Not applicable
Missing grab bars or pressure-mounted vertical safety pole (“super pole”) in any non-bathroom areas of the home?	□	□	□
Broken or boarded-up windows?	□	□	□
Missing storm windows?	□	□	□	□ Storms removed for summer or unneeded
Hardware for drapes, shades, and/or curtains that are difficult for client to use?	□	□	□
Plaster or drywall with cracks or holes?	□	□	□
A.4f. Thermostat displays that are difficult for client to access and read?	□	□	□
A.4g. Washing machine and/or dryer in a location that is difficult for client to access?	□	□	□

A.5. (baseline only) Does the home already contain older adult home modifications?

□ Yes Go to A.5a □ No (Go to A.6)

A.5a optional Summarize existing older adult home modifications:

HOME EXTERIOR (Skip section if A.2=condominium or cooperative housing unit in multi-unit building)

A.6. Does the home exterior have:	Yes, and is a hazard	Yes, but is not a hazard	No	Not Applicable
Foundation that is crumbling or has open holes	□	□	□	□ Foundation not observed
Missing bricks, siding, or other outside material	□	□	□
Roof problems (e.g., missing material, sagging, or hole(s))	□	□	□	□ Roof not observed
Slippery walking surfaces	□	□	□
Gutters or downspouts in poor repair	□	□	□
(Ask only if A.2=mobile/manufactured home) Skirting in need of repair	□	□	□
A.7. In the area leading to the home entrance, are there uneven walking surfaces or broken steps?	□	□	□
A.8. Do the steps just outside the home entrance have missing or broken handrails?	□	□	□	□ No entry steps
A.9. Is the exterior poorly lit at entrances? “Poorly lit” means (1) lights cause shadows on the walkway; (2) glare is thrown from the lights (e.g., unfrosted bulbs, or no shades or covers on lights); (3) bulb wattage is inadequate for size of walkway; (4) light bulb is burned out; or (5) bulb is missing from socket- If visit is during daylight hours, ask client.	□	□	□
A.10. Is the address number posted on the home missing or not visible from the street for emergency responders?	□	□	□
A.11. Does the client need to stretch or bend to reach into the mailbox?	□	□	□	□ No mailbox

HOME SAFETY DEVICES INSIDE HOME For multi-unit buildings, inspect only the unit itself, not common areas.

	Yes, and is a hazard	Yes, but is not a hazard	No	Not Applicable
Are smoke detectors missing or not functioning? Ask client before testing detector(s). If multiple detectors are or should be present, choose “yes, and is a hazard) if ≥1 is not present where it should be or is not working.	□		□ Smoke detectors present & functioning
Are carbon monoxide alarms missing or not functioning? Ask client before testing alarm(s). If multiple alarms are or should be present, choose “yes, and is a hazard) if ≥1 is not present where it should be or is not working.	□		□ CO alarms present & functioning	□ No CO alarm needed-no combustion appliances or attached garage
Are light switches difficult to locate in the dark?	□	□	□
Are light switches difficult for the client to operate? (e.g., not equipped with rocker-style or other easy-to function switches)	□	□	□
Can the client reach light switches only if they stretch or bend?	□	□	□
Is hot water heater thermostat in need of repair or set above 120 degrees?	□	□	□	□ Did not observe hot water heater

Floors inside home For multi-unit buildings, inspect only the unit itself, not common areas.

	Yes, and is a hazard	Yes, but is not a hazard	No
Height differences exist between flooring transitions (e.g., between rooms or between different types of flooring)	□	□	□
Floors and floor surfaces (e.g., tile, carpet) pose slipping or tripping hazards or are in need of repair (e.g., uneven surfaces, holes, tears in flooring, torn carpet, carpet curling, uneven surfaces in hardwood, etc.)	□	□	□
Do you have to walk over or around wires or cords (e.g., lamp, telephone, or extension cords)?	□	□	□
Are rugs in rooms other than the kitchen and bathroom not secured? Answer “no” if no rugs are present in rooms other than kitchen or bathroom.	□	□	□

ENTRANCE DOORS AND DOORS INSIDE HOME For units in multi-unit buildings, inspect only the unit itself, not common areas.

	Yes, and is a hazard	Yes, but is not a hazard	No
Do doors have door knobs instead of door levers? (PD&R 2011)	□	□	□
Do doors have non-zero thresholds?	□	□	□
Are doors missing or in need of repair (e.g., unable to close properly, holes, swing awkwardly)?	□	□	□
Do exterior (entrance) doors:
D.4a Have door locks that are difficult for the client to operate?	□	□	□
D.4b Missing peephole or have peephole client can reach only if they stretch or bend?	□	□	□
D.4c Missing automatic door openers or hands-free door hold open capability?	□	□	□
D.4d Missing storm door(s) or have storm doors in need of repair?	□	□	□
D.4e Missing slide latches, chains, or other devices for added security?	□	□	□

Stairs and Steps INSIDE HOME

For condominiums and apartments in multi-unit buildings, consider only stairs located within the unit, not those in common areas.

E.1 Are there stairs or steps inside home? □Yes Go to E.1a □ No (Go to E.2)

E.1a Can you (the field person) access the stairs or steps inside home?

□Yes Go to E.2 □ No (Go to F.1)

	Yes, and is a hazard	Yes, but is not a hazard	No
Are any stair treads or risers missing, broken, or uneven?	□	□	□
Is light fixture over the stairs missing?	□ Go to E.4	□ Go to E.4	□ (Go to E.3a)
E.3a. Is there only one light switch for the stairway light (i.e., switch is located only at the top or only at the bottom of the stairs)?	□	□	□
E.3b. Is the stairway poorly lit? “Poorly lit” means (1) lights cause shadows on the walkway; (2) glare is thrown from the lights (e.g., unfrosted bulbs, or no shades or covers on lights); (3) bulb wattage is inadequate for size of walkway; (4) light bulb is burned out; or (5) bulb is missing from the socket- If visit is during daylight hours, ask client.	□	□	□
Do stair treads have slippery surfaces, whether carpeted or bare?	□	□	□
Are handrails or balusters missing, loose, broken, at an inappropriate height, or do not extend the length of the stairs?	□	□	□
E.6. Are handrails present on only one side of the stairs?	□	□	□

KITCHEN:

F.1 Can you (the field person) access the kitchen?

□ Yes Go to F.2 □ No (Go to G.1)

	Yes, and is a hazard	Yes, but is not a hazard	No	Not Applicable
Does the client need to stretch or bend to reach items they often use, including the microwave? You may need to look at the items on high shelves and ask the client if they often use these materials.	□	□	□
Is the kitchen poorly lit? “Poorly lit” means (1) lights cause shadows on the walkway; (2) glare is thrown from the lights (e.g., unfrosted bulbs, or no shades or covers on lights); (3) bulb wattage is inadequate for size of walkway; (4) light bulb is burned out; or (5) bulb is missing from the socket- If visit is during daylight hours, ask client	□	□	□
Are outlets near wet areas missing GFCIs?	□	□	□	□ No outlets are present near wet areas
Is the kitchen missing a fire extinguisher or is the fire extinguisher only partly charged or empty?	□	□	□
F.6. Does the faucet have knobs instead of handles or levers? (PD&R 2011)	□	□	□
F.7. Are kitchen cabinets or shelves missing or in need of repair?	□	□	□
F.8. Are kitchen cabinets missing rollout trays or lazy susans? (PD&R 2011)	□	□	□
F.9. Is stove missing an automatic turnoff device?	□	□	□
F.10. Are kitchen rugs not secured? Answer “no” if no kitchen rugs are present	□	□	□

BATHROOM(S):

1. How many bathrooms are present in the home? ____ Include both full and half baths in this count. (If answer>1, program REDCap to ask G.2-G.11 for each bathroom)

2. Can you (the field person) access bathroom (Insert number)? □ Yes (Go to G.3) □ No (Go to G.2 for bathroom 2, or H.1 if there is only 1 bathroom)

3. (Ask client): "¿Es este el baño que usas normalmente?"□ Yes (Go to G.4) □ No (Go to G.2 for bathroom 2, or H.1 if there is only 1 bathroom)

4. Descriptive Information for Bathroom (insert number)

G.4a (baseline only and only if G.1>1. Describe location (e.g., floor number and other description to help keep bathrooms in order at follow-up visit)____________

G.4b Is Bathroom (insert number) a full or half bath?

□ Full (Ask all questions G.5-G.16) □ Half (Skip questions G.16a-G.16e)

For follow-up visit, include the following grantee guidance: Complete the questions below for each bathroom, following the same order of bathrooms you used at baseline)

	Yes, and is a hazard	Yes, but is not a hazard	No
Is the toilet missing grab bars or have grab bars that are poorly located or in need of repair?	□	□	□
Is the toilet standard height (i.e., lower than comfort height? Do not include portable devices (PD&R 2011)	□	□	□
Is toilet paper holder poorly positioned for client?	□	□	□
Is toilet seat missing or in need of repair?	□	□	□
Is toilet handle difficult for client to use?	□	□	□
Are the hot water pipes beneath the sink exposed?	□	□	□
Is the bathroom poorly lit? “Poorly lit” means (1) lights cause shadows on walking area; (2) glare is thrown from the lights (e.g., unfrosted bulbs, or no shades or covers on lights); (3) bulb wattage is inadequate for the room space; (4) light bulb is burned out; or (5) bulb is missing from the socket	□	□	□
Are bathroom rugs not secured? Answer “no” if no bathroom rugs are present	□	□	□
Is bathroom mirror and cabinet missing or poorly positioned to meet client’s needs?	□	□	□
Is bathroom missing GFCI outlets?	□	□	□
Do the faucets have knobs instead of levers or handles? (PD&R 2011)	□	□	□
Tub and shower questions for Bathroom (insert number)
G.16a Does the tub or shower have a slippery surface?	□	□	□
G.16b Is the shower or bathtub area missing grab bars or have grab bars poorly located or in need of repair?	□	□	□
G.16c Does the bathroom contain only a bathtub (no shower)?	□	□	□
G.16d Is the shower missing a flexible handheld hose?	□	□	□
G.16e Does the shower have a threshold? (If G.1=1, go to H.1; otherwise, if G.1>1, go to G.2 for the second bathroom)	□	□	□

BEDROOM:

Visually assess only one bedroom. Check the same bedroom at the follow-up visit. Visually check the bedroom even if they currently sleep in the living room or other area.

1. Number of bedrooms in home: __________

2. Preguntarle al cliente dónde duerme habitualmente.

□ Recámara Describe location of client’s bedroom, including whether it is located on a different floor from the main living area and kitchen: ___________(Go to H.3)

If there is more than one bedroom, ask the client to identify which bedroom they sleep in most frequently or would like to sleep in if it was accessible and visually check this bedroom. Add notes on location of bedroom so you can check the same bedroom at follow-up visit. Visually check the bedroom even if they currently sleep in the living room or other area.

□ Sala Go to H.2a

□ Otra habitación que no se haya mencionado. Specify:_____ Go to H.2a

H.2a Si la persona no duerme en una habitación, pregúntele el porqué. ________________

H.2b Si la persona no duerme en una habitación, pregúntele en qué habitación le gustaría dormir, si pudiera, or visually check the bedroom that the client could logically sleep in (e.g., if he/she could get up the stairs). (Describe location of this bedroom, including whether it is located on a different floor from the main living area and kitchen, or a different floor from the bathroom the client normally uses. At follow-up visit, if H.1>1, note if this bedroom is the same one the client slept in at baseline.) _____________________

H.3 Can you (the field person) access the bedroom identified in H.2 or H.2b? □ Yes Go to H.4 □ No (Go to I.1)

	Yes, and is a hazard	Yes, but is not a hazard	No	Not applicable
H.4 Is the light near the bed missing or hard to reach?	□	□	□
H.5 Is the path from the bed to the bathroom poorly lit? “Poorly lit” means (1) lights cause shadows on the walkway; (2) glare is thrown from the lights (e.g., unfrosted bulbs, or no shades or covers on lights); (3) bulb wattage is inadequate for size of walkway; (4) light bulb is burned out; or (5) bulb is missing from the socket- If visit is during daylight hours, ask the client	□	□	□
H.6 Does client have to stretch to reach the switch for the ceiling light fixture or ceiling fan? You may need to look to see if fixtures with chains are present in the bedroom and, if yes, ask the client if they have troubling reaching the chain.	□	□	□	□ no ceiling light fixture or fan present

ACCESSIBILITY (PD&R 2011)

I.1 Does the client use a wheelchair, or is a wheelchair is present in the home at the time of the visit?

☐ Yes (Go to I.2) ☐ No (Go to I.3)

(Complete I.2 only if client uses a wheelchair)

I.2 (Ask only if person uses a wheelchair) While in a wheelchair, would the client find it difficult to access the following features or rooms in this home:	Yes, and is a hazard	Yes, but is not a hazard	No
I.2a Electrical outlets? (PD&R 2011)	□	□	□
I.2b Electrical switches (e.g., light switches)?	□	□	□
I.2c Climate controls (thermostats)?	□	□	□
I.2d All kitchen cabinets?	□	□	□
I.2e Kitchen countertops?	□	□	□
I.2f Bathrooms?	□	□	□
I.2g Bedrooms?	□	□	□
I.3 Is the bathroom missing:	□	□	□
I.3a A roll-under sink? (Ask only if person uses a wheelchair)	□	□	□
I.3b A walk-in tub or accessible shower?	□	□	□
I.3c An easy-transfer toilet (e.g., raised or comfort height)?	□	□	□
I.3d Sufficient turn-around space (e.g., if person uses a wheelchair, walker, or cane or needs help from another person)?	□	□	□
I.3e Easy-access storage area?	□	□	□
I.4 Are the floors uneven or do they have high-pile carpet?	□	□	□
I.5 Does the home currently have any of the following features:
I.5a Narrow doors or hallways?	□	□	□
I.5b Areas of the home that are not on the same level, meaning there are steps between rooms?	□	□	□
I.6 Can the home be entered from the outside only by using steps?	□	□	□

VISION, HEARING, AND COGNITIVE ISSUES (PD&R 2015)

J.1 Does the client have issues with their vision? (Consult client’s responses to C.3 on the Client Impact Evaluation Interview form if needed to answer this question.) □ Yes (Go to J.1a) □ No (Go to J.2)

J.1a Are electrical and light switches missing tactile cues?

□Yes, and is a hazard □ Yes, but is not a hazard □ No

J.1b Are stairs or changes in surface missing visual (e.g., color contrast) or tactile cues?

□Yes, and is a hazard □ Yes, but is not a hazard □ No

J.1c Are thermal controls missing digital displays with large font, backlit features?

□Yes, and is a hazard □ Yes, but is not a hazard □ No

J.2 Does the client have issues with their hearing? (Consult client responses to C.3 on the Client Impact Evaluation Interview form if needed to answer this question.) □ Yes Go to J.2a □ No (Go to J.3)

J.2a Are safety devices (smoke, CO alarms) missing visual cues?

□ Yes, and is a hazard □ Yes, but is not a hazard □ No

J.2b Does the doorbell use bells instead of flashing lights?

□ Yes, and is a hazard □ Yes, but is not a hazard □ No

J.3 Does the client have cognition issues? (Consult client responses to C.3 on the Client Impact Evaluation Interview form if needed to answer this question.) □ Yes Go to J.3a □ No (end home hazard checklist)

J.3a Is the range missing conductive heating that could prevent burning?

□ Yes, and is a hazard □ Yes, but is not a hazard □ No

Comments about Home Hazard Check (e.g., areas that were not accessible, conditions found that did not fit any checklist categories, etc.):

1 Code for this document: Black font=Question asked of the grantee; Blue italics = Instruction for the grantee; yellow highlighted italics: Instruction for REDCap programmer.