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Purpose: To tap into your experience to determine risks that could harm residents.

Who should use this tool? Anyone who works in or provides services to this nursing home.

How should you use this tool? Provide as much detail as possible when answering the two questions below. You will need details to understand how you can prevent harm. Drop off your completed assessment in the locked box located at _____________.

When should you use this tool? This form can be filled out by anyone who works here at any time. At a minimum, everyone should complete this form twice a year.

Name (optional):

Job title/department:

Date:

Please describe how you think the next resident in your area or facility will be harmed.

Please describe what you think can be done to prevent or minimize this harm.