Pediatric Environmental Home Assessment - Resident Reported Information

Instructions: This page represents the second and third pages of the three-page Pediatric Environmental Home Assessment Survey form. It is designed to capture key information that the resident provides you during your interview and home walk-through. After reading the scenario and viewing the video clips and the photos, please complete the form by check marking the boxes and filling in the blanks. Please add notes in the "Notes" box to clarify your answers. Complete the form, including the section requesting some limited information about yourself, then click on . You will get a webpage confirming your form submission. Then move on to the Nursing Care Plan - Part 1 or go back to review the Scenario. Try to click only once for each form. If you want to change your information, resubmit it and explain the changes in the Notes Box. You do not need to complete the forms in the order listed.

The website will send an email to NCHH's Judith Agyeman at jagyeman@nchh.org with your completed form. She will review it and compare it to a completed form that we think best matches the scenario. She will get back to you with the results within five business days. Please feel free to contact her directly. If there are questions, it will be helpful if you have saved the form submission as described above.

Hints:

If you are impatient and want to see how you did, click here to download a completed form that we think best matches the scenario.
The bolded items represent concerns that call for action. Click on the bolded word to go to the Nursing Care Plan that describes the action you should consider.
If you want to know why an issue is important, click on the Section heading or the text in in the left column to get more information.
If you have problems with the form, contact Susan Aceti at saceti@nchh.org.

We are constantly learning from your feedback. Please use the "Notes" box in each section to help us understand how to do better and to identify environmental health problems we may have missed. You are always welcome to send us an email.

Information on Person Submitting Form

Name:

Organization:

Email:

Have You Attended Essentials for Healthy Homes Practitioner Course?

If so, what date:

If you are a nurse, which description fits best?

Child Safety - If young children present
Young Children Present	Yes	No
Coffee, hot liquids, and foods	Out of child’s reach	Within child’s reach
Cleaning supplies stored	Out of child’s reach	Within child’s reach
Medicine and vitamins stored	Out of child’s reach	Within child’s reach
Child (less than six years old) been tested for lead poisoning	Within past 6 months Result:	More than six months Result	No
Child watched by an adult while in the tub	Always	Most of the time	No
Home’s hot water temperature	Less than 120°F	More than 120°F	Don’t know
Non-accordion toddler gates used	At top of stairs	At bottom of stairs	No
Crib mattress	Fits well	Loose
Window guards	Yes	No
Window blind cords	Split cord	Looped cord
NOTES:

10320 Little Patuxent Parkway, Suite 500 • Columbia, MD 21044
Phone: 410.992.0712 • Fax: 443.539.4150