2. Do NOT Sign In or Create an Account

   You do NOT need to create an account or sign in to complete this form. For the majority of our users, it's best not to create an account or sign in. 

4. Name
5. Email Address
7. Address
9. City
10. State
11. Zip Code
13. Phone Number
14. Preferred Contact Method

    1. Email
    2. Phone

    1. Either
18. Home Safety Checklist to Prevent Falls at Home

    This home fall prevention checklist was developed by the Centers for Disease Control and Prevention through their STEADI Program (Stopping Elderly Accidents, Deaths and Injuries). It is one of many resources North Metro Fire uses to help educate residents and reduce risk of injury in the home for all ages. 

20. Stairs and Steps (Indoors and Outdoors)
22. Do you have stairs or steps leading into your home or within your home?

    1. Yes
    2. No
24. Are there papers, shoes, books, or other objects on the stairs?

    1. Yes
    2. No

    TIP: Always keep objects off the stairs to help prevent tripping or falling. 

26. Are some steps broken or uneven?

    1. Yes
    2. No

    TIP: Fix any steps that are loose or uneven. 

28. Is there a light and light switch at the top and bottom of the stairs?

    1. Yes
    2. No

    TIP: Have an electrician put in an overhead light and light switch at the top and bottom of the stairs. You can even get light switches that glow to help you see them at night. Alternatively, you can add battery-operated (and solar-powered for outdoor steps) lighting solutions so you can better see your stairs. 

30. Has a stairway light bulb burned out?

    1. Yes
    2. No

    TIP: Replace any burned out light bulbs to provide optimal lighting and visibility.

32. Is the carpet on the steps loose or torn?

    1. Yes
    2. No

    TIP: Firmly attach the carpet to every step, or remove the carpet and attach non-slip rubber treads to the stairs.

34. Are the handrails loose or broken? Is there a handrail on only one side of the stairs?

    1. Yes
    2. No

    TIP: Ensure handrails are secured and/or fixed and  consider installing handrails on both sides of the stairway. 

38. Floors
41. When you walk through a room, do you have to walk around furniture?

    1. Yes
    2. No

    TIP: Ask someone to help move the furniture so your path is clear.

43. Do you have throw rugs on the floor?

    1. Yes
    2. No

    TIP: Rugs are common culprits that cause someone to trip or slip and fall. Remove the rugs, or use double-sided tape or a non-slip backing so the rugs won't slip. 

45. Are there papers, shoes, books or other objects on the floor?

    1. Yes
    2. No

    TIP: Pick up things that are on the floor, and always keep objects off the floor to reduce your risk of tripping and falling. 

47. Do you have to walk over or around wires or cords (like lamp, telephone or extension cords)?

    1. Yes
    2. No

    TIP: Coil or tape cords and wires next to the wall so you can’t trip over them. If needed, have an electrician put in another outlet.

51. Kitchen
53. Are things you use often in the kitchen stored on high shelves?

    1. Yes
    2. No

    TIP: Keep things you use often on the lower shelves (about waist high).

55. Is your step stool sturdy?

    1. Yes
    2. No

    TIP: If you have difficulty balancing or have physical weaknesses, it's best to avoid using a step stool. If you must use a step stool, get one with a bar to hold on to. Never use a chair as a step stool, and have someone close by to assist you if needed. 

59. Bedrooms and Bathrooms
61. Is the light or lamp near your bed hard to reach?

    1. Yes
    2. No

    TIP: Place a lamp close to your bed where it's easy to reach. This not only helps to avoid falling out of bed from overreaching, but it also allows you to easily turn on a light when having to get up in the middle of the night. 

63. Is the path from your bed to the bathroom dark?

    1. Yes
    2. No

    TIP: Put in a nightlight so you can see where you’re walking. Some nightlights go on by themselves after dark.

65. Is the tub or shower floor slippery?

    1. Yes
    2. No

    TIP: Put a non-slip rubber mat or self-stick strips on the floor of the tub or shower.

67. Do you need some support when you get in and out of the tub or up from the toilet?

    1. Yes
    2. No

    TIP: Have grab bars installed next to and inside the tub and next to the toilet.

69. Electronic Signature Agreement*

    By checking the "I agree" box below, you agree and acknowledge that 1) you have completed the home safety checklist, 2) you would like to be entered in the quarterly drawing to have a free lunch delivered to you by North Metro Fire firefighters/staff, 3) you give North Metro Fire the right to contact you and coordinate the delivery of lunch, and 4) in the event there is an issue with the food, which will be prepared by a local restaurant, you will not hold North Metro Fire responsible and will address any issues directly with the food vendor. 

    1. I agree.
71. Electronic Signature
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