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 what you can do, and why.

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? _____ Tell me more about using the telephone.
6. Are walkways within your home open and free of clutter? _____ Tell me more about Stairways & Halls.
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 Lighting & Contrast.
14. Are any rooms or areas of your home dark, and in need of lamps or lights to help you function better? _____ Tell me more about Lighting & Contrast.
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? _____ Tell me more about Bathrooms.
17. Does your tub have a mat in it or gripper strips to help prevent a fall? _____ Tell me more about Bathrooms.
18. Are there chairs or seats in your home that you have trouble getting up and out of? _____ Tell me more about Safety in the Living Room.
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? _____ Tell me more about Kitchen safety.
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 Kitchen safety.
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. Do you need to use a stepladder or a step stool to reach shelves, light fixtures, or other high items? _____ Tell me more about Kitchen safety.
26. Is your home more than you can care for independently? _____
27. Can you reduce the number of rooms you and the family regularly use and need to care for? _____
28. If you have a multi-level home, could you live on one floor? _____
29. 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 Lighting & Contrast.
2. Are you taking advantage of natural lighting coming from windows, or are you using heavy curtains that block the light? _____ Tell me about full spectrum light bulbs
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? _____ Tell me more about Living Rooms.
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? _____ Tell me more about glare.
9. Is the lighting immediately outside your door good enough for you to lock/unlock your door in a short amount of time? _____ Tell me more about Entrances.

Color & Contrast

1. Would it help to have contrasting colored plates against a tablecloth or place mat? _____ Tell me more about Dining Room safety.
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 outlets, as in a bedroom or study.
4. Do you feel safe in your one-color tub and shower? _____ Tell me more about safety in the bathroom.
5. Do you sometimes have difficulties locating doorways? _____ Tell me more about Entrances.
6. Are your furniture and surroundings all of a similar color? _____ Tell me more about Lighting & Contrast.
7. Having problems with doors left open? _____ Tell me more about Upper Body Protective Techniques.
8. Problems locating and using household equipment controls? _____ Tell me more about Kitchens.
9. Difficulties with same colored pans on same colored stove? _____ Tell me more about Kitchens.
10. Would it help to paint the stair handrail a contrasting color to the surrounding carpet or wall? _____ Tell me more about Stairways & Halls.