Room Paint Condition Observations and Temporary Measures Needed Primary Play Intact ☐ Area Not Intact ☐ Living Room Intact ☐ Not Intact ☐ Dining Room Intact ☐ Not Intact ☐ Kitchen Intact ☐ Not Intact ☐ Family Room Intact ☐ Not Intact ☐ Child’s Intact ☐ Bedroom Not Intact ☐ Parent’s Intact ☐ Bedroom Not Intact ☐ Other Intact ☐ Bedroom Not Intact ☐ Bathroom Intact ☐ Not Intact ☐ Porch Entry Intact ☐ Not Intact ☐ Yard Intact ☐ Not Intact ☐ Nurse’s Signature Date
Room Paint Condition Observations and Temporary Measures Needed Primary Play Area ☐ Intact ☐ Not Intact Living Room ☐ Intact ☐ Not Intact Dining Room ☐ Intact ☐ Not Intact Kitchen ☐ Intact ☐ Not Intact Family Room ☐ Intact ☐ Not Intact Child’s Bedroom ☐ Intact ☐ Not Intact Parent’s Bedroom ☐ Intact ☐ Not Intact Other Bedroom ☐ Intact ☐ Not Intact Bathroom ☐ Intact ☐ Not Intact Porch Entry ☐ Intact ☐ Not Intact Yard ☐ Intact ☐ Not Intact Nurse’s Signature Date