Safety Environment Assessment for Foster Care by csgirla


									                                                       You will need Acrobat Reader 6.0 or higher in
                                                            order to complete this form online.

                    CHILDREN'S SERVICES
                                                                                       Safety Environment Assessment for Foster Care

                    Name of Foster Family                                                                                          Date (yyyy/mm/dd)

                                                                                                             Comments               Date Rechecked
                                          Accommodations                                Yes   No       (mandatory if No checked)      (yyyy/mm/dd)     Yes   No

                    The home is equipped with working smoke detectors on all

                    A fire extinguisher is working and easily accessible.

                    The thermostat on the hot water tank is set so that boiling
                    water does not come out from the taps.

                    Unused electrical outlets have plastic outlet covers.

                    The stairs are built securely and protected by guards or
                    railings, free of objects and well lighted.

                    Matches and lighters are stored in a place inaccessible to

                    All medicines are clearly labelled and stored in a locked
                    All weapons including firearms, BB guns, pellet guns, sport
                    and hunting knives, and cross bows, bows and arrows are kept
                    in a locked facility. Ammunition to be locked and stored
                    separate from weapons. All firearms are trigger locked.
                    Cleaning agents and toxic substances including alcohol and
                    tobacco are stored in original containers, labeled and kept out
                    of reach of children.
                    The crib, playpen meets the current standards for safety.

                    Rear-facing car seats for 0-20 lb. child. Car seat with tether
                    and bolt for 20 - 40 lb. child.

                                                                                                             Comments               Date Rechecked
                                                    Outdoors                            Yes   No       (mandatory if No checked)      (yyyy/mm/dd)     Yes   No

                    Equipment such as lawn mowers, snow blowers, garden tools
                    are stored in a safe place ( i.e. fire, flood, tornado warnings,
                    Pesticides and chemicals are inaccessible to children.

                    The play area is free of litter and sharp objects.

                    All play equipment such as swings, slides, climbing equipment
                    and seesaws are in good repair.

                    Check for presence of outdoor hazards (i.e. location and
                    safety of pools, ponds, irrigations, ditches, lakes, etc.).

                                                                                                             Comments               Date Rechecked
                                                    General                             Yes   No       (mandatory if No checked)      (yyyy/mm/dd)     Yes   No

                    The family practices fire drills and has a written evacuation
                    plan in place.

                    A first aid kit is available.

                    There is a list of emergency telephone numbers handy.

                    There is easy access to medical services.

                    Confidential records stored in a secure place.

                    The children are never left unattended in the bathtub or
                    shower. The tub is drained when child is removed. Water is
                    kept at a safe temperature.
                    All children under the age of 12 are placed in the back seat of
                    the vehicle.

                                                                                                             Comments               Date Rechecked
                                                     Farm                               Yes   No       (mandatory if No checked)      (yyyy/mm/dd)     Yes   No

                    The farmyard is free of debris, glass, old cars, appliances,
                    garbage, etc.
CS 3606 (2004/11)

                    Dugout, wells, holes, ponds, sloughs, or septic tanks on the
                    farm are fenced.

                    The machinery has guards around the belts and chains.
                                                                                                 Comments                     Date Rechecked
                        Farm - Continued                                Yes     No         (mandatory if No checked)            (yyyy/mm/dd)   Yes     No

    Supervision is provided when children are around farm
    machinery, such as tractors, trucks and augers.

    Supervision is provided when children are around livestock.

    Keys are taken out of the machinery, vehicles, snowmobiles
    and ATV's when not in use.

    The workshop is inaccessible to children or kept locked.

    Caution is taken when using and storing fertilizers, chemicals,
    spray and other toxic substances.

    Medication and other treatments for farm animals are
    inaccessible to children.

    Children are supervised around livestock feed. (i.e. grain bin,
    hay or straw bales).

                                                                      Additional Comments

    Foster Care Worker/Licensing Officer Signature                                                                     date (yyyy/mm/dd)

    Foster Parent Signature                                                                                            date (yyyy/mm/dd)

                                                                                                                   Print Form              Save form
Reset Form

To top