Download "user manual"

MGC
DOC 89/11
Appendix 9 – RISK ASSESSMENT CHECKLIST
HOMECARE INSTALLATION RISK ASSESSMENT CHECKLIST
Patient’s Address
Patient’s Name
Installation Date
Concentrator
Installation Type
Backup
Cylinders
Liquid
Cylinders
Multiple
Units
Gas
Cylinders
Ambulatory
Cylinders
Self fill
system
Pipeline
Observations /
Recommendations
Potential Risks
Property Access Profile
Yes
No
No suitable vehicle parking / Poor access/ surface condition to property / Tarmac
Steep / Narrow / Spiral / Limited use Stairs to property / No guard rail
Access to property using lift
Patient / Carer Profile
Patient / Carer does not understand how to operate equipment/other language
Patient / Carer not able to operate equipment
Patient / Carer smokes
Patient using other equipment in combination with oxygen therapy equipment
Usage Area Profile (for Equipment)
Equipment required to be used in more than one location / needs to be mobile
Equipment used in Workshop / Garage
Equipment used in Kitchen
Equipment used within 1.5 metres of mains electrical appliances
Equipment used within 3 metres of open flame
Usage area not adequately ventilated and or maintained clean and suitable
Usage area floor: carpet / linoleum / cork / other adsorbent material
Pets / Dog present
Storage Area Profile (for Cylinders / Containers)
Storage in garage / workshop / basement
Storage in cupboard / basement / poorly ventilated area
Stored within 1.5 meters of oils & grease / LPG / Paints / flammable materials
Stored within 1.5 meters of open flame
Installer’s Comments / Other Concerns or Potential Risks
Installer’s Name / Signature
Date
Company internal Comments / Actions
Company internal Name /
Signature
Date
35