Adult Foster Care |
House |
entering home |
Bath bench |
Apartment |
House/townhome |
inside home |
Bath not on first floor |
Apartment/condo |
Independent living facility |
inside, present at both sides |
Bed and bath are not on the first floor |
Assisted Living |
Mobile home |
inside, present on left side |
Bed not on first floor |
Condominium |
No permanent address |
inside, present on right side |
Extended tub bench |
Correctional facility |
Nursing Home |
none entering home |
Grab bars present (bathtub) |
Extended care facility |
Orphanage |
none inside home |
Grab bars present (toilet) |
Foster care |
Private Residence |
other (must comment) |
Hand held shower |
Group Home |
Residential facility |
other (see comments) |
Raised toilet |
Home |
Ronald McDonald House |
outside, present at both sides |
Ramps present at home |
Home Care Staff |
Shelter |
outside, present on left side |
Shower grab bar |
Homeless |
SNF |
outside, present on right side |
Shower stall |
Hope Lodge |
Staying with family |
present at both sides |
Shower/tub chair |
Hospitality house |
Staying with friends |
present of both sides |
Toilet |
Hotel |
Townhome/townhouse |
present on left side |
Toilet grab bar |
Hotel/motel |
|
present on right side |
Tub/shower combo |
|
|
stairs (1 railing present) |
Tub/shower is not walk in |
|
|
stairs (2 railings present) |
|
|
|
stairs to enter home |
|
|
|
stairs within home |
|
|
|
entering home |
|
|
|
<number> |
|
|
|
<number x # flights> |
|
Living Situation Subject |
Living Conditions Type |
Adoptive parent(s) |
Grandfather |
Chipped paint |
No running water |
Alone |
Grandmother |
Insects/pests |
No smoke detector |
Aunt |
Grandparents |
No air conditioning |
No working appliances |
Birth family |
Half-brother |
No electricity |
Other (see comments) |
Brother |
Half-sister |
No heat |
Paint chipped |
Child(ren) |
Host family |
No hot water |
Stairwells unsafe |
Child(ren), adult |
Legal guardian |
No indoor plumbing |
Unable to assess |
Child(ren), dependent |
Mother |
No lighting |
Unsafe stairwells |
Domestic partner |
Mother and partner |
No phone |
Windows broken |
Father |
Other (see comments) |
|
|
Father and partner |
Other relative(s) (specify) |
|
|
Foster care |
Parent(s) |
|
|
Foster family |
Room mate |
|
|
Foster parent(s) |
Sibling(s) |
|
|
Friend(s) |
Significant other |
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Grandchild(ren) |
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