List specific additional risk(s): Comments: SAFETY No risk identified in this section (skip to FINANCIAL section) Yes No Possible Water temperature safety: Needs any support to adjust water temperature to avoid scalding. Fire evacuation safety: Needs any assistance to evacuate when a fire or smoke alarm sounds. Household chemical safety: Needs any support to avoid serious injury from household chemicals. Vehicle safety: Needs any assistance to remain safe around traffic, while getting in or out of a vehicle, or while riding in vehicles. Court-mandated protection: Someone else has a court-mandated condition or restriction against them to address this person’s safety. (e.g. protective orders or restraining orders to keep this person safe) If yes, list court order and date: Evidence, signs, or circumstances of significant increased risk of abuse or Significant risk of exploitation: exploitation. Enters into contracts that he/she may not be able to complete: Consider the person’s capacity to make an informed decision about contracts or agreements he/she enters into. Safety and cleanliness of the residence: Conditions within the residence may lead to injury, illness, eviction, or significant loss of property. Consider any other important, serious safety issues at home or in any other setting. Other safety issues: (e.g. workplace equipment, bullying, harassment) List specific additional safety risk(s): Comments: FINANCIAL No risk identified in this section (skip to MENTAL HEALTH section) Yes Possible No History
List specific additional risk(s): Comments: SAFETY No risk identified in this section (skip to FINANCIAL section) Yes No Possible Water temperature safety: Needs any support to adjust water temperature to avoid scalding. Fire evacuation safety: Needs any assistance to evacuate when a fire or smoke alarm sounds. Household chemical safety: Needs any support to avoid serious injury from household chemicals. Vehicle safety: Needs any assistance to remain safe around traffic, while getting in or out of a vehicle, or while riding in vehicles. Court-mandated protection: Someone else has a court-mandated condition or restriction against them to address this person’s safety. (e.g. protective orders or restraining orders to keep this person safe) If yes, list court order and date: Significant risk of exploitation: Evidence, signs, or circumstances of significant increased risk of abuse or exploitation. Enters into contracts that he/she may not be able to complete: Consider the person’s capacity to make an informed decision about contracts or agreements he/she enters into. Safety and cleanliness of the residence: Conditions within the residence may lead to injury, illness, eviction, or significant loss of property. Other safety issues: Consider any other important, serious safety issues at home or in any other setting. (e.g. workplace equipment, bullying, harassment) List specific additional safety risk(s): Comments: FINANCIAL No risk identified in this section (skip to MENTAL HEALTH section) Yes Possible No History
2-Risk_Identification_Tool_1-20-2015.docx