Information on Person Submitting Form
Name:
Organization:
Email:
Have You Attended
Essentials for Healthy Homes Practitioner Course?
Not Sure
Yes
No
If so, what date:
Did you complete Part
1 & 2 of Survey and Part 1 & 2 of Nursing Care Plan?
Yes
No
If yes, provide the date you completed Part 1 of the Survey:
If you
are a nurse, which description fits best?
Public Health Nurse
Visiting Nurse
School Nurse
Nursing Student
Other Type of Nurse
I am not a nurse
If yes, do want continuing education credits?
Yes
No
If yes, do you want an incentive?
Yes
No
If you want an incentive, pick one.
CO Alarm
Lead Dust Wipe Kit
10% off Moisture Meter
Home Safety
CONCERN
NURSE TO DO
FAMILY TO DO
Renovation / remodeling
■
See
“Age of Home” above.
■
Review
items in “Family To Do” column with family.
■
See
“Age of Home” above.
■
If
the home was built pre-1978 and there is a child less than six years
old:
o
get a lead
paint inspection or risk assessment.
o
repair any
lead hazards based on state and local regulations and requirements.
Consult with state CLPPP.
■
If
the home was built pre-1978 and there is no child less than six years
old:
o
consult
with the CLPPP at your state and local departments of health about
lead-safe renovation.
o
Change
behaviors, such as modifying dust generating techniques and containing
the work area.
Will do
actions listed above except:
Will
advise family as listed above except:
Stairs,
walls, railings, porches, lighting
■
If
family owns home, then counsel to change behaviors, such as making minor
repairs to fix loose railings.
■
If
family rents home, then counsel them to talk with their landlord.
■
Review
items in “Family To Do” column with family.
■
If homeowner, then make necessary repairs.
■
If renter,
then talk with your landlord about needed repairs. Consider calling the
local board of health for possible code violations.
Will do
actions listed above except:
Will
advise family as listed above except:
Poison control
■
Provide
national poison control number 800-222-1222 to family.
■
Review
items in “Family To Do” column with family.
■
Post
the national poison control number 800-222-1222 near telephone.
Will
do actions listed above except:
Will
advise family as listed above except:
Family fire
escape plan
■
Counsel
to change behaviors, such as develop a family safety plan.
■ Get
more fire safety information at
www.usa.safekids.org
■
Review
items in “Family To Do” column with family.
■ Develop
a family safety plan.
■ Need
to know two ways out of the house.
■
Need
to have a place to meet after you are outside the house.
■
Teach
children the family safety plan for escaping your home in a fire and
practice it
Will
do actions listed above except:
Will
advise family as listed above except:
Electrical appliances
■
Counsel
to change behavior.
■
Review
items in “Family To Do” column with family.
■
Do
not use electrical appliances near water.
Will
do actions listed above except:
Will
advise family as listed above except:
Matches and lighters
■
Counsel
to change behavior.
■
Review
items in “Family To Do” column with family.
■
Do
not store matches and lighters where children can reach them.
Will do
actions listed above except:
Will advise
family as listed above except:
Exterior environment
■
If
abundant trash and debris, counsel family about waste management.
■ If
waste containment is the problem, counsel family to talk with landlord.
■
See
“Infestations” above.
■
If
the home was built pre-1978, contact the childhood lead poisoning
prevention program (CLPPP) at your state and local departments of health
for information about chipping, peeling paint. See “Age of Home” above.
■
Review
items in “Family To Do” column with family.
■
See
“Infestations” above.
■
See
“Age of Home” above.
Will do
actions listed above except:
Will
advise family as listed above except:
Child Safety
Hot
liquids / cleaning supplies / medicines
■
Counsel
to change behaviors.
■
Review
items in “Family To Do” column with family.
■ Do
not have hot liquids, cleaning supplies, or medicines within a child’s
reach.
Will do
actions listed above except:
Will
advise family as listed above except:
Lead
testing for children less than 6 years old
■
If
the home was built pre-1978, counsel the family to have the child’s
blood tested for lead.
■
See
“Age of Home” above.
■ Review
items in “Family To Do” column with family.
■ Contact
the childhood lead poisoning prevention program (CLPPP) at your state
and local departments of health about lead testing resources.
■ See
“Age of Home” above.
Will do
actions listed above except:
Will
advise family as listed above except:
Child watched by an
adult while in tub
■
Counsel
to change behavior.
■
Educate
family about importance of not leaving children unattended in the tub.
■
Review
items in “Family To Do” column with family.
■ Do
not leave children unattended in the tub.
Will do
actions listed above except:
Will advise
family as listed above except:
Hot
water temperature
■ Educate
family about dangers of scalding.
■ Review
items in “Family To Do” column with family.
■ Set
hot water temperature to <120 F
Will do
actions listed above except:
Will
advise family as listed above except:
Toddler gates
■
Counsel
family to install non-accordion toddler gates at the top and bottom of
stairways.
■
Review
items in “Family To Do” column with family.
■ Contact
local injury prevention program to determine whether there are toddler
gate resources available.
■
Install
non-accordion toddler gates at the top and bottom of stairways.
Will do
actions listed above except:
Will advise
family as listed above except:
Crib
mattress
■
Counsel
family that crib mattress should fit snugly next to the crib so that
there is no gap.
■
If
two adult fingers can be placed between the mattress and the crib, then
counsel the family to immediately replace the mattress.
■
Review
items in “Family To Do” column with family.
■ Put
your baby to sleep in a crib with a firm, flat mattress and no soft
bedding underneath.
■
Ensure
that your crib mattress fits snugly next to the crib so that there is no
gap.
Will do
actions listed above except:
Will advise
family as listed above except:
Window guards
■
Counsel
family about window safety.
■ Contact
local injury prevention program to determine whether there are window
guard resources available.
■
Review
items in “Family To Do” column with family.
■
Contact
local injury prevention program to determine whether there are window
guard resources available.
■
Install
window guards.
Will do
actions listed above except:
Will advise
family as listed above except:
Window blind cords
■
Counsel
family to keep window blind cords out of children’s reach and to
purchase childproofing items for cord safety.
■
Review
items in “Family To Do” column with family.
■
Keep
window blind cords out of children’s reach
■
Purchase
childproofing items for cord safety.
Will do
actions listed above except:
Will advise
family as listed above except: