mounted in the kitchen area and all occupants know how to use it? Yes If there are any other fire extinguishers in the home, do all occupants No / / know their location and use? Yes Is there at least one carbon monoxide detector installed in V-i No / / accordance with the recommendations? manufacturer’s Yes V-j Is there a fireplace in the home? No / / Yes If yes, is a screen kept in front of the fireplace when it is being used? No / / Yes Are all ashes from wood/coal heating stoves and fireplaces kept V-k No / / outside in a tightly covered metal container and stored safely Yes away from combustible materials? Required Action Date Required Action No/Yes or VI Weapons Completed Recommendation Are there any firearms, rifles or shotguns in the home? No / / VI-a Yes If yes, list the type and number of weapons: / / Is each weapon licensed in compliance with applicable state and No / / local standards? Yes If yes, are guns and ammunition kept separately in locked No / / storage areas? Yes Are any other safety measures taken to avoid the unauthorized No / / handling of the weapons and potential injury? Be specific. Yes Required Action Date Required Action No/Yes VII Property/Bodies of Water or Completed Recommendation Is there a swimming pool at the residence? VII-a No / / Yes If yes, check one: In ground Above ground If yes, does the pool meet all the local building installation, safety No / / requirements and regulations? Yes If yes, is there a fence surrounding the pool that is a minimum of No / / four feet? Yes Is the residence near a pond, ravine etc.? No / / VIII-b Yes Is there a sufficient plan to keep child(ren) safe from busy streets No / / VIII-c or/and traffic? Yes Applicant(s) agrees to above noted required actions Applicant’s signature: X signature: Second applicant’s X When all required actions have been satisfactorily completed, worker and supervisor must complete check boxes and sign below: Physical facilities are in good condition and present no hazard to the health and safety of No Yes children 18 NYCRR 443.3(a)(2). Home is in substantial compliance with all applicable provisions of state, local laws and No Yes ordinances, rules and regulations concerning health and safety OCFS-5183E (4/2018)
mounted in the kitchen area and all occupants know how to use it? Yes If there are any other fire extinguishers in the home, do all occupants know their location and use? No Yes / / V-i Is there at least one carbon monoxide detector installed in accordance with the manufacturer’s recommendations? No Yes / / V-j Is there a fireplace in the home? No Yes / / If yes, is a screen kept in front of the fireplace when it is being used? No Yes / / V-k Are all ashes from wood/coal heating stoves and fireplaces kept outside in a tightly covered metal container and stored safely away from combustible materials? No Yes / / VI Weapons No/Yes Required Action or Recommendation Date Required Action Completed VI-a Are there any firearms, rifles or shotguns in the home? No Yes / / If yes, list the type and number of weapons: / / Is each weapon licensed in compliance with applicable state and local standards? No Yes / / If yes, are guns and ammunition kept separately in locked storage areas? No Yes / / Are any other safety measures taken to avoid the unauthorized handling of the weapons and potential injury? Be specific. No Yes / / VII Property/Bodies of Water No/Yes Required Action or Recommendation Date Required Action Completed VII-a Is there a swimming pool at the residence? If yes, check one: In ground Above ground No Yes / / If yes, does the pool meet all the local building installation, safety requirements and regulations? No Yes / / If yes, is there a fence surrounding the pool that is a minimum of four feet? No Yes / / VIII-b Is the residence near a pond, ravine etc.? No Yes / / VIII-c Is there a sufficient plan to keep child(ren) safe from busy streets or/and traffic? No Yes / / Applicant(s) agrees to above noted required actions Applicant’s signature: X Second applicant’s signature: X When all required actions have been satisfactorily completed, worker and supervisor must complete check boxes and sign below: Physical facilities are in good condition and present no hazard to the health and safety of children 18 NYCRR 443.3(a)(2). No Yes Home is in substantial compliance with all applicable provisions of state, local laws and ordinances, rules and regulations concerning health and safety No Yes OCFS-5183E (4/2018)
18-OCFS-ADM-07-OCFS-5183E.docx