Site______________

Date_____________
RN ____________

Home Environmental Health and Safety Assessment Tool

Assessment Yes No N/A Standard of Practice

Home built before 1978 O O O • Test homes built
before 1978 for lead.
Home tested for lead O O O
• Maintain home to
Living space in basement O O O prevent chipping or
Attached garage O O O peeling paint
• Remove shoes indoors
Home radon test O O O • Test first three floors of
Home radon ventilation system O O O all homes for radon
• Do not idle car in
Living space in basement O O O garage
• Ensure proper venting
Combustion heating source O O O
of all combustion
Gas, kerosene or propane heating sources.
O O O
space heater • Annual assessment to
ensure proper
Wood stove O O O
function.
• Do not use grills, or
Fireplace O O O
generators indoors
Gas dryer O O O • Gas dryers, hot water
Vented O O O heaters and stove
need to vent outdoors
Gas hot water heater O O O
Vented O O O
Gas stove O O O
Well water O O O • Routine well testing
Lead pipes O O O and maintenance of
private wells.
Water tested for contaminants O O O • Review consumer
Known contaminants: O O O confidence reports for
public water supply
Smoke detector O O O • Smoke detector on all
Carbon monoxide detector O O O floors and in
bedrooms
Fire extinguisher O O O • Carbon monoxide
Fire evacuation route O O O detector on all levels
in homes with
Emergency phone numbers O O O combustion source or
Disaster plan O O O garage
Shelter –in-place supplies O O O

© University of Maryland, Environmental Health Education Center 3/07

 N/
Assessment Yes No A Standard of Practice
Insects in home O O O • Use of integrated pest
management
Rodents in home O O O techniques for
If yes what: ________________________________ controlling pests.
Pesticide spraying in home O O O • Use least hazardous
methods of pest
If yes what / how often:______________________ control
Pesticide contract O O O
Frequency:_________________________________
Air freshener used in home O O O • Minimize use of air
fresheners. Use less
Candles O O O hazardous and
Plug-ins O O O irritating alternatives
Incense O O O to control odors.
• Use of low VOC
How many times per day: O O O household cleaners
Use of strong smelling cleaners O O O and green cleaning
techniques.
• See federal and state
Tuna fish served in home O O O recommended fish
consumption
If yes, how often per week:__________________ advisories
• Wash all fruits and
vegetables before
Fresh fruit/vegetables used O O O eating
• Consider organic or
Local/ organic products used O O O locally grown
products
Mercury thermometer in house O O O • Use non-mercury
containing medical
Other mercury devices O O O devices
Needle boxes for needles O O O • Dispose of all mercury
devices and batteries
Use of traditional or cultural per local hazard waste
O O O
remedies containing mercury collection procedures
Smoking allowed in home O O O • Institute no smoking
indoors policy
House smells like smoke O O O
Cigarette products present O O O

© University of Maryland, Environmental Health Education Center 3/07