Lesson 2: Home Safety & Emergency Preparedness - Template

Home Hazard Assessment Worksheet

Kitchen Safety Assessment

Hazard	Present?	Action Required	Priority
Unattended cooking	□ Yes □ No		□ High □ Medium □ Low
Grease buildup	□ Yes □ No		□ High □ Medium □ Low
Flammable items near cooktop	□ Yes □ No		□ High □ Medium □ Low
Appliances near water	□ Yes □ No		□ High □ Medium □ Low
Overloaded outlets	□ Yes □ No		□ High □ Medium □ Low
Improperly stored cleaning products	□ Yes □ No		□ High □ Medium □ Low
Unsecured knives	□ Yes □ No		□ High □ Medium □ Low
Missing fire extinguisher	□ Yes □ No		□ High □ Medium □ Low

Bathroom Safety Assessment

Hazard	Present?	Action Required	Priority
Slippery floors	□ Yes □ No		□ High □ Medium □ Low
Missing grab bars	□ Yes □ No		□ High □ Medium □ Low
Non-GFCI outlets	□ Yes □ No		□ High □ Medium □ Low
Water heater set too high	□ Yes □ No		□ High □ Medium □ Low
Unsecured medications	□ Yes □ No		□ High □ Medium □ Low
Electrical appliances near water	□ Yes □ No		□ High □ Medium □ Low

Living Area Safety Assessment

Hazard	Present?	Action Required	Priority
Loose rugs	□ Yes □ No		□ High □ Medium □ Low
Cluttered walkways	□ Yes □ No		□ High □ Medium □ Low
Trailing cords	□ Yes □ No		□ High □ Medium □ Low
Overloaded outlets	□ Yes □ No		□ High □ Medium □ Low
Unstable furniture	□ Yes □ No		□ High □ Medium □ Low
Blind cords	□ Yes □ No		□ High □ Medium □ Low
Unsecured windows	□ Yes □ No		□ High □ Medium □ Low

Utility Area Safety Assessment

Hazard	Present?	Action Required	Priority
Improperly stored chemicals	□ Yes □ No		□ High □ Medium □ Low
Dryer lint buildup	□ Yes □ No		□ High □ Medium □ Low
Flammables near heat sources	□ Yes □ No		□ High □ Medium □ Low
Missing carbon monoxide detector	□ Yes □ No		□ High □ Medium □ Low
Improper wiring	□ Yes □ No		□ High □ Medium □ Low
Leaking pipes	□ Yes □ No		□ High □ Medium □ Low

Home Emergency Plan

Household Information

Home address: _______________________________________

Phone number: _______________________________________

Number of residents: _____ adults _____ children _____ pets

Special needs: _______________________________________

Emergency Contact Information

Contact Type	Name	Phone Number	Address
Local Emergency Contact
Out-of-Area Contact
Neighbor
Family Doctor
Poison Control		0344 892 0111
Gas Company
Electric Company
Water Company

Evacuation Routes

Primary exit route from each room: - Bedroom 1: _______________________________________ - Bedroom 2: _______________________________________ - Living room: _______________________________________ - Kitchen: _______________________________________ - Other: _______________________________________

Secondary exit route from each room: - Bedroom 1: _______________________________________ - Bedroom 2: _______________________________________ - Living room: _______________________________________ - Kitchen: _______________________________________ - Other: _______________________________________

Meeting point outside home: _______________________________________

Alternative meeting point: _______________________________________

Emergency Responsibilities

Task	Responsible Person	Backup Person
Assisting children
Assisting elderly/disabled
Pet evacuation
Grabbing emergency kit
Shutting off utilities
Contacting emergency services

Utility Shut-off Locations

Electricity: _______________________________________

Gas: _______________________________________

Water: _______________________________________

Instructions for shut-off: - Electricity: _______________________________________ - Gas: _______________________________________ - Water: _______________________________________

Emergency Kit Inventory

Water and Food

Item	Quantity	Expiration Date	Replacement Date
Bottled water
Canned food
Dry food
Special diet items
Pet food
Manual can opener
Utensils/plates

Safety and First Aid

Item	Quantity	Expiration Date	Replacement Date
First aid kit
Prescription medications
Glasses/contact lenses
Dust masks
Work gloves
Whistle
Emergency blankets

Tools and Supplies

Item	Quantity	Condition	Replacement Date
Torch/flashlight
Extra batteries
Radio (battery/wind-up)
Multi-tool
Duct tape
Plastic sheeting
Basic tools
Fire extinguisher

Documents and Communication

Item	Included?	Last Updated	Storage Location
ID copies	□ Yes □ No
Insurance policies	□ Yes □ No
Medical information	□ Yes □ No
Bank details	□ Yes □ No
Emergency contacts	□ Yes □ No
Local maps	□ Yes □ No
Cash (small denominations)	□ Yes □ No
Mobile phone charger	□ Yes □ No

Home Security Assessment

Exterior Security

Feature	Status	Action Required	Priority
Exterior lighting	□ Adequate □ Needs improvement		□ High □ Medium □ Low
Door security	□ Adequate □ Needs improvement		□ High □ Medium □ Low
Window security	□ Adequate □ Needs improvement		□ High □ Medium □ Low
Landscaping	□ Adequate □ Needs improvement		□ High □ Medium □ Low
House number visibility	□ Adequate □ Needs improvement		□ High □ Medium □ Low
Outbuilding security	□ Adequate □ Needs improvement		□ High □ Medium □ Low

Door Security Details

Door Location	Type	Lock Type	Additional Security	Action Required
Front	□ Solid □ Hollow	□ Deadbolt □ Lever □ Knob	□ Chain □ Viewer □ Smart
Back	□ Solid □ Hollow	□ Deadbolt □ Lever □ Knob	□ Chain □ Viewer □ Smart
Side/Other	□ Solid □ Hollow	□ Deadbolt □ Lever □ Knob	□ Chain □ Viewer □ Smart

Window Security Details

Window Location	Type	Lock Working?	Additional Security	Action Required
Front	□ Single □ Double □ Sash	□ Yes □ No	□ Limiters □ Bars □ Sensors
Back	□ Single □ Double □ Sash	□ Yes □ No	□ Limiters □ Bars □ Sensors
Side	□ Single □ Double □ Sash	□ Yes □ No	□ Limiters □ Bars □ Sensors
Upstairs	□ Single □ Double □ Sash	□ Yes □ No	□ Limiters □ Bars □ Sensors

Key Management

Key Type	Number of Copies	Who Has Access	Storage Location
Front door
Back door
Windows
Outbuildings
Spare keys

Emergency Drill Log

Date	Drill Type	Participants	Time to Complete	Issues Identified	Corrective Actions
	□ Fire □ Intruder □ Medical □ Other
	□ Fire □ Intruder □ Medical □ Other
	□ Fire □ Intruder □ Medical □ Other
	□ Fire □ Intruder □ Medical □ Other

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