ENVIRONMENTAL EVALUATION QUESTIONNAIRE

You can start by using this questionnaire to evaluate your home for safety and lighting. Then follow the "Tell me more" links to learn about the changes you can make to increase safety, organization, and accessibility throughout yout your home.

Safety in Your Home

1. Do you have working smoke detectors and carbon monoxide detectors? _____ Tell me more.
2. Do you know how to change the batteries in the detectors? _____
3. Do you have an emergency escape plan from your home? _____
4. Do you have a current list of emergency numbers you can access and use, including your doctor's number? _____ Tell me more about using the telephone.
5. Is the telephone accessible and can you use it easily in an emergency? _____
6. Are walkways within your home open and free of clutter? _____ Tell me more about organization.
7. Is the carpet on the stairs secure or is it worn or loose? _____
8. Are there railings on every set of stairs? _____
9. Are the railings secure, or are they wobbly, loose or missing? _____
10. Are there any area rugs that are loose on the floor, or other potential tripping hazards that should be either removed or secured? _____ Tell me more.
11. Are there any loose cords or wires that could be a tripping hazard? _____
12. Do you have a working fire extinguisher in the kitchen? _____ In the house? _____ Tell me more.
13. Are there any light bulbs that need to be replaced to give you better lighting in a room or a hallway? _____  Tell me more about Home Modifications.
14. Are any rooms or areas of your home dark, and in need of lamps or lights to help you function better? _____ 
15. Does your bathroom need rails in the tub or near the toilet for you to use these facilities with more safety and confidence? _____
16. Are the rugs on the floor of the bathroom backed with a non-skid material? _____ 
17. Does your tub have a mat in it or gripper strips to help prevent a fall? _____ 
18. Are there chairs or seats in your home that you have trouble getting up and out of? _____ 
19. Are the appliances in your home safe and easy for you to use? _____
20. Can you read the dials on the stove, microwave, or other appliances? _____ 
21. Do you need better lighting near these appliances? _____
22. Do you need to mark the dials for ease of use? _____ Tell me more about labeling and marking.
23. Do you need to change to a smaller or table-top type of appliance for ease of use? _____
24. Do you need to sit rather than stand for many of your daily tasks, cooking, washing dishes, washing clothes? _____
25. Can you reduce the number of rooms you and the family regularly use and need to care for? _____
26. If you have a multi-level home, could you live on one floor? _____
27. Can you make your house easy-maintenance, or do you need to hire help to maintain it? _____

Lighting and Glare

1. Does the lighting in each room, closet or other location help you move around safely, or are there potential accident areas? _____ Tell me more about Home Modifications.
2. Are you taking advantage of natural lighting coming from windows, or are you using heavy curtains that block the light? _____ 
3. Do you need different lighting solutions for activities that take different amounts of time? _____
4. Does the lighting adequately cover potential accident areas such as stairs and landing, entrance hall, or any other level changes? _____
5. Do you need "spot" lighting for specific tasks, for example, when you're shaving, applying makeup, reading a book, or preparing food? _____
6. Do your chairs or sofa face windows where bright sunlight could cause glare? _____ 
7. Are there areas in your home that have glossy tiles, shiny enamel paint, or mirrors that cause glare? _____
8. When you view your TV or use your computer are both you and the TV/computer protected from glare? _____ 
9. Is the lighting immediately outside your door good enough for you to lock/unlock your door in a short amount of time? _____ 

Color & Contrast

1. Would it help to have contrasting colored plates against a tablecloth or place mat? _____ Tell me more about Home Modifications.
2. Would it help to have two chopping boards: one white and another black? _____
3. Can you easily locate your wall sockets? _____ Tell me more about Household Safety.
4. Do you feel safe in your one-color tub and shower? _____ 
5. Do you sometimes have difficulties locating doorways? _____ 
6. Are your furniture and surroundings all of a similar color? _____ 
7. Are you having problems with doors left open? _____ Tell me more about Upper Body Protective Techniques.
8. Are you having problems locating and using household equipment controls? _____ Tell me more about Labeling and Marking.
9. Difficulties with same colored pans on same colored stove? _____ 
10. Would it help to paint the stair handrail a contrasting color to the surrounding carpet or wall? _____