Monthly Safety Report

Please complete by the 20th of each month.

Monthly Safety Report*

Date/Time*

:

Support Address*

You have selected apartment 101, if you meant 313 please change the dropdown above.

You have selected apartment 313, if you meant 101 please change the dropdown above.

Location Phone #*

SC's Email Address*

The SC will get a copy for filing at the location

Fire Sprinkler System

Does this location have a sprinkler system?*

Yes No

What does the fire sprinkler system gauge level indicate? (Report reading of 40 or below to Manager)*

Tamper seal is in tact?*

Yes No

The area near the sprinkler riser is dry (no leaking evident)*

Yes No

The area around the sprinkler riser (1 metre) is clear (no storage)*

Yes No

Sprinkler caps are in place throughout the home*

Yes No

Explain / elaborate*

Fire Department Connection Cap is Present and Secure (located on the exterior wall at the front of the house)*

Yes No (contact Maintenance)

Hot Water Temperature

The water temperature at all hot water sink taps in the location is 120 degrees F or under

Yes No

Hot water temperature at MAIN Bath: SHOWER

Hot water temperature at MAIN Bath: BATH

Hot water temperature at ALTERNATE Bath: SHOWER

Hot water temperature at ALTERNATE Bath: BATH

Temperature reading at sink over 120 degrees

Location of sink where temperature was taken

Manager's Report

Any accident in the location during the previous month?*

Yes No

Specify the accident and any action taken to minimize re-occurrence*

Any incidents of violence reported during the previous month?*

Yes No

Did the violence involve a person supported?*

Yes No

Does the person have an ESS or a BSP in place?*

Yes No

Specify violence reported*

List any item to be brought to the attention of the Health and Safety Committee

General Checklist - some items updated Sep 29, 2022 labelled "NEW"

General Checklist*

Comments (If needed)

Stove and Oven Check

Stove top is clean, including any applicable elements*

Yes No

The oven door and all stove/oven controls work properly*

Yes No

It is obvious that the oven is clean / has been recently cleaned*

Yes No

The range hood/filter was checked and is clean and free of grease*

Yes No N/A

What action did you take as a result?*

Who was specifically assigned to clean the oven and/or range hood within 24hrs?*

First Name

Last Name

Bathroom Checklist

Bathroom Checklist*

Bathroom Checklist
	Ok	No	N/A
Bathroom vent working	Bathroom Checklist: Bathroom vent working (Ok)	Bathroom vent working (No)	Bathroom vent working (N/A)
Bath tub has slip protection	Bath tub has slip protection (Ok)	Bath tub has slip protection (No)	Bath tub has slip protection (N/A)
Jacuzzi/Air tub GFCI Testing	Jacuzzi/Air tub GFCI Testing (Ok)	Jacuzzi/Air tub GFCI Testing (No)	Jacuzzi/Air tub GFCI Testing (N/A)
Toilet seat secure and not loose	Toilet seat secure and not loose (Ok)	Toilet seat secure and not loose (No)	Toilet seat secure and not loose (N/A)

Comments (If needed)

Mold and Moisture

Mold and moisture check*

Mold and moisture check
	Ok	Problem	N/A
No mold or moisture is visible in any common room	Mold and moisture check: No mold or moisture is visible in any common room (Ok)	No mold or moisture is visible in any common room (Problem)	No mold or moisture is visible in any common room (N/A)
No mold or moisture is visible in any bedroom	No mold or moisture is visible in any bedroom (Ok)	No mold or moisture is visible in any bedroom (Problem)	No mold or moisture is visible in any bedroom (N/A)
No mold or moisture is visible in any closet	No mold or moisture is visible in any closet (Ok)	No mold or moisture is visible in any closet (Problem)	No mold or moisture is visible in any closet (N/A)
No mold is apparent on window sills, bathroom caulking, etc.	No mold is apparent on window sills, bathroom caulking, etc. (Ok)	No mold is apparent on window sills, bathroom caulking, etc. (Problem)	No mold is apparent on window sills, bathroom caulking, etc. (N/A)

Comments (If needed)

Kitchen Checklist

Kitchen Checklist*

Kitchen Checklist
	Ok	No	N/A
Oven mitts available	Kitchen Checklist: Oven mitts available (Ok)	Oven mitts available (No)	Oven mitts available (N/A)
Sharp utensils stored safely	Sharp utensils stored safely (Ok)	Sharp utensils stored safely (No)	Sharp utensils stored safely (N/A)
Thermometers in fridge and freezer within range (37°F(3°C) and 40°F (5°C) for Fridge, 0°F (-18°C) or below for Freezer)	Thermometers in fridge and freezer within range (37°F(3°C) and 40°F (5°C) for Fridge, 0°F (-18°C) or below for Freezer) (Ok)	Thermometers in fridge and freezer within range (37°F(3°C) and 40°F (5°C) for Fridge, 0°F (-18°C) or below for Freezer) (No)	Thermometers in fridge and freezer within range (37°F(3°C) and 40°F (5°C) for Fridge, 0°F (-18°C) or below for Freezer) (N/A)
Fire extinguisher in kitchen away from stove	Fire extinguisher in kitchen away from stove (Ok)	Fire extinguisher in kitchen away from stove (No)	Fire extinguisher in kitchen away from stove (N/A)

Comments (If needed)

Medication Cabinet / Health / Assistive Devices

Medication Cabinet / Health / Assistive Devices*

Comments (If needed)

Vehicle Checklist

Comments (If needed)

Vehicle Checklist*

Vehicle Checklist
	Ok	No	N/A
Accessible vehicle fire extinguisher available	Vehicle Checklist: Accessible vehicle fire extinguisher available (Ok)	Accessible vehicle fire extinguisher available (No)	Accessible vehicle fire extinguisher available (N/A)
Extinguisher is secured	Extinguisher is secured (Ok)	Extinguisher is secured (No)	Extinguisher is secured (N/A)
Extinguisher tag checked and updated	Extinguisher tag checked and updated (Ok)	Extinguisher tag checked and updated (No)	Extinguisher tag checked and updated (N/A)
Lift and Q-straints in good working order	Lift and Q-straints in good working order (Ok)	Lift and Q-straints in good working order (No)	Lift and Q-straints in good working order (N/A)
First Aid kit available and contents complete	First Aid kit available and contents complete (Ok)	First Aid kit available and contents complete (No)	First Aid kit available and contents complete (N/A)

Outdoor Checklist

Outside Checklist*

Outside Checklist
	Ok	No	N/A
Lawn furniture / outdoor equipment in good repair	Outside Checklist: Lawn furniture / outdoor equipment in good repair (Ok)	Lawn furniture / outdoor equipment in good repair (No)	Lawn furniture / outdoor equipment in good repair (N/A)
Grade entrance/exit clear	Grade entrance/exit clear (Ok)	Grade entrance/exit clear (No)	Grade entrance/exit clear (N/A)
Walking paths clear for egress	Walking paths clear for egress (Ok)	Walking paths clear for egress (No)	Walking paths clear for egress (N/A)

Comments (If needed)

Other Items

Were there any health and safety issues identified at the time of this report that require follow-up by maintenance?*

Yes No

Describe the health and safety issue*

Other issues surrounding the Monthly Safety Report

Indicate the concern, people notified, and action taken

Concerns discussed with staff

Indicate the concern, people notified, and action taken

Signatures

Date/Time*

Employee's Name*

First Name

Last Name

Employee's Signature*

[clear]

Use your mouse or finger to draw your signature above

Manager's Name*

First Name

Last Name

Manager's Signature*

[clear]

Use your mouse or finger to draw your signature above

This form gets submitted to the appropriate Support Manager and to the Manager QA, Manager Health and Wellness, and to appropriate Administrative staff.

If there are outstanding maintenance requests Maintenance will be notified.

If there are accidents over the past month, or if there are problems with orientations, the Director HR will be notified.

If there are instances of violence, the Director HR and the Directors Support will be notified.

	Ok	No	N/A
All smoke detectors were tested and are working	General Checklist: All smoke detectors were tested and are working (Ok)	All smoke detectors were tested and are working (No)	All smoke detectors were tested and are working (N/A)
Carbon monoxide detector(s) checked and working	Carbon monoxide detector(s) checked and working (Ok)	Carbon monoxide detector(s) checked and working (No)	Carbon monoxide detector(s) checked and working (N/A)
All fire extinguishers checked and tags dated	All fire extinguishers checked and tags dated (Ok)	All fire extinguishers checked and tags dated (No)	All fire extinguishers checked and tags dated (N/A)
NEW - Emergency lights - not every location has emergency lighting	NEW - Emergency lights - not every location has emergency lighting (Ok)	NEW - Emergency lights - not every location has emergency lighting (No)	NEW - Emergency lights - not every location has emergency lighting (N/A)
NEW - Flashlight working	NEW - Flashlight working (Ok)	NEW - Flashlight working (No)	NEW - Flashlight working (N/A)
Electric Door Strikes disengaged as required	Electric Door Strikes disengaged as required (Ok)	Electric Door Strikes disengaged as required (No)	Electric Door Strikes disengaged as required (N/A)
Fire Safety Plan located in front of communication binder and in Health and Safety binder PLEASE CHECK TO MAKE SURE IT IS THE MOST RECENT/ACCURATE VERSION	Fire Safety Plan located in front of communication binder and in Health and Safety binder PLEASE CHECK TO MAKE SURE IT IS THE MOST RECENT/ACCURATE VERSION (Ok)	Fire Safety Plan located in front of communication binder and in Health and Safety binder PLEASE CHECK TO MAKE SURE IT IS THE MOST RECENT/ACCURATE VERSION (No)	Fire Safety Plan located in front of communication binder and in Health and Safety binder PLEASE CHECK TO MAKE SURE IT IS THE MOST RECENT/ACCURATE VERSION (N/A)
Lint filters on dryer clean	Lint filters on dryer clean (Ok)	Lint filters on dryer clean (No)	Lint filters on dryer clean (N/A)
There are no oil-based paints, propane tanks, gasoline, or other flammable liquids within the location	There are no oil-based paints, propane tanks, gasoline, or other flammable liquids within the location (Ok)	There are no oil-based paints, propane tanks, gasoline, or other flammable liquids within the location (No)	There are no oil-based paints, propane tanks, gasoline, or other flammable liquids within the location (N/A)
No combustible materials near furnace/hot water heater	No combustible materials near furnace/hot water heater (Ok)	No combustible materials near furnace/hot water heater (No)	No combustible materials near furnace/hot water heater (N/A)
NEW - 1 Metre clearance around furnace, hot water heater, electrical panel, sprinkler shut off	NEW - 1 Metre clearance around furnace, hot water heater, electrical panel, sprinkler shut off (Ok)	NEW - 1 Metre clearance around furnace, hot water heater, electrical panel, sprinkler shut off (No)	NEW - 1 Metre clearance around furnace, hot water heater, electrical panel, sprinkler shut off (N/A)
All exit ramps and stairs are free and clear	All exit ramps and stairs are free and clear (Ok)	All exit ramps and stairs are free and clear (No)	All exit ramps and stairs are free and clear (N/A)
Bedroom(s) doorways unobstructed	Bedroom(s) doorways unobstructed (Ok)	Bedroom(s) doorways unobstructed (No)	Bedroom(s) doorways unobstructed (N/A)
Windows open and close readily	Windows open and close readily (Ok)	Windows open and close readily (No)	Windows open and close readily (N/A)
Exit doors open and close easily	Exit doors open and close easily (Ok)	Exit doors open and close easily (No)	Exit doors open and close easily (N/A)
Power bars used instead of extension cords	Power bars used instead of extension cords (Ok)	Power bars used instead of extension cords (No)	Power bars used instead of extension cords (N/A)
Cords not frayed	Cords not frayed (Ok)	Cords not frayed (No)	Cords not frayed (N/A)
Step stool in good working order	Step stool in good working order (Ok)	Step stool in good working order (No)	Step stool in good working order (N/A)
Land-line (corded and cordless phones are operational)	Land-line (corded and cordless phones are operational) (Ok)	Land-line (corded and cordless phones are operational) (No)	Land-line (corded and cordless phones are operational) (N/A)
Weekend emergency number sticker on phone	Weekend emergency number sticker on phone (Ok)	Weekend emergency number sticker on phone (No)	Weekend emergency number sticker on phone (N/A)
Battery-operated radio available	Battery-operated radio available (Ok)	Battery-operated radio available (No)	Battery-operated radio available (N/A)
All staircase railings are secure	All staircase railings are secure (Ok)	All staircase railings are secure (No)	All staircase railings are secure (N/A)
All pictures and wall hangings are secure	All pictures and wall hangings are secure (Ok)	All pictures and wall hangings are secure (No)	All pictures and wall hangings are secure (N/A)
No storage under stairwells	No storage under stairwells (Ok)	No storage under stairwells (No)	No storage under stairwells (N/A)
All lamp sockets have bulbs (not empty)	All lamp sockets have bulbs (not empty) (Ok)	All lamp sockets have bulbs (not empty) (No)	All lamp sockets have bulbs (not empty) (N/A)
Wiring not exposed	Wiring not exposed (Ok)	Wiring not exposed (No)	Wiring not exposed (N/A)
Labels in tact on all cleaning supplies containers	Labels in tact on all cleaning supplies containers (Ok)	Labels in tact on all cleaning supplies containers (No)	Labels in tact on all cleaning supplies containers (N/A)
Furniture checked for integrity, sharp edges, etc.	Furniture checked for integrity, sharp edges, etc. (Ok)	Furniture checked for integrity, sharp edges, etc. (No)	Furniture checked for integrity, sharp edges, etc. (N/A)
Walkways unobstructed by loose/worn carpet or extension cords	Walkways unobstructed by loose/worn carpet or extension cords (Ok)	Walkways unobstructed by loose/worn carpet or extension cords (No)	Walkways unobstructed by loose/worn carpet or extension cords (N/A)
HRV air quality box setting	HRV air quality box setting (Ok)	HRV air quality box setting (No)	HRV air quality box setting (N/A)
Ensure BBQ propane tank is not expired	Ensure BBQ propane tank is not expired (Ok)	Ensure BBQ propane tank is not expired (No)	Ensure BBQ propane tank is not expired (N/A)
Ensure BBQ propane tank is secured, hose attached properly, no smell of propane	Ensure BBQ propane tank is secured, hose attached properly, no smell of propane (Ok)	Ensure BBQ propane tank is secured, hose attached properly, no smell of propane (No)	Ensure BBQ propane tank is secured, hose attached properly, no smell of propane (N/A)
Visual Check from the opening, crawlspace is free and clear of any storage items	Visual Check from the opening, crawlspace is free and clear of any storage items (Ok)	Visual Check from the opening, crawlspace is free and clear of any storage items (No)	Visual Check from the opening, crawlspace is free and clear of any storage items (N/A)

	Ok	No	N/A
Lifting devices in good order	Medication Cabinet / Health / Assistive Devices: Lifting devices in good order (Ok)	Lifting devices in good order (No)	Lifting devices in good order (N/A)
Contaminated medication bottle available	Contaminated medication bottle available (Ok)	Contaminated medication bottle available (No)	Contaminated medication bottle available (N/A)
Emergency phone numbers posted on cabinet door	Emergency phone numbers posted on cabinet door (Ok)	Emergency phone numbers posted on cabinet door (No)	Emergency phone numbers posted on cabinet door (N/A)
Water temperature thermometer in cabinet	Water temperature thermometer in cabinet (Ok)	Water temperature thermometer in cabinet (No)	Water temperature thermometer in cabinet (N/A)
First Aid kit available and contents complete	First Aid kit available and contents complete (Ok)	First Aid kit available and contents complete (No)	First Aid kit available and contents complete (N/A)
Medication within expiry date	Medication within expiry date (Ok)	Medication within expiry date (No)	Medication within expiry date (N/A)
Discontinued medications returned to pharmacy	Discontinued medications returned to pharmacy (Ok)	Discontinued medications returned to pharmacy (No)	Discontinued medications returned to pharmacy (N/A)
Cabinet lock in working order	Cabinet lock in working order (Ok)	Cabinet lock in working order (No)	Cabinet lock in working order (N/A)
Only health-related items in cabinet	Only health-related items in cabinet (Ok)	Only health-related items in cabinet (No)	Only health-related items in cabinet (N/A)
Canes, walkers and wheelchairs in perfect working conditions	Canes, walkers and wheelchairs in perfect working conditions (Ok)	Canes, walkers and wheelchairs in perfect working conditions (No)	Canes, walkers and wheelchairs in perfect working conditions (N/A)
Personal protective equipment available	Personal protective equipment available (Ok)	Personal protective equipment available (No)	Personal protective equipment available (N/A)
WSIB package available	WSIB package available (Ok)	WSIB package available (No)	WSIB package available (N/A)
Cabinet is clean	Cabinet is clean (Ok)	Cabinet is clean (No)	Cabinet is clean (N/A)
Grab bars / transfer pole bars	Grab bars / transfer pole bars (Ok)	Grab bars / transfer pole bars (No)	Grab bars / transfer pole bars (N/A)
Each person who requires a lift to evacuate at night has a dedicated lift and shelf for it	Each person who requires a lift to evacuate at night has a dedicated lift and shelf for it (Ok)	Each person who requires a lift to evacuate at night has a dedicated lift and shelf for it (No)	Each person who requires a lift to evacuate at night has a dedicated lift and shelf for it (N/A)
Working Forehead scanner thermometer- tested and ready to go.	Working Forehead scanner thermometer- tested and ready to go. (Ok)	Working Forehead scanner thermometer- tested and ready to go. (No)	Working Forehead scanner thermometer- tested and ready to go. (N/A)