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  Annual assessment to
space heater
ensure proper
Wood stove O O O
function.
 Do not use grills,
Fireplace O O O
or 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.
 Use least
Pesticide spraying in home O O O hazardous methods
If yes what / how often:
of pest 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
IfTuna
yes, fish
howserved in home
often per week: O O O recommended fish
advisories
consumption
 Wash all fruits and
vegetables before
Fresh fruit/vegetables used O O O eating
 Consider or
organic
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