{"id":709,"date":"2019-03-10T21:04:17","date_gmt":"2019-03-10T21:04:17","guid":{"rendered":"http:\/\/djcareservices.com\/?page_id=709"},"modified":"2019-03-11T14:47:19","modified_gmt":"2019-03-11T14:47:19","slug":"service-user-assessment","status":"publish","type":"page","link":"http:\/\/djcareservices.com\/service-user-assessment\/","title":{"rendered":"Service User Risk Assessment"},"content":{"rendered":"\n\n<div class=\"wpcf7 no-js\" id=\"wpcf7-f705-o1\" lang=\"en-GB\" dir=\"ltr\">\n<div class=\"screen-reader-response\"><p role=\"status\" aria-live=\"polite\" aria-atomic=\"true\"><\/p> <ul><\/ul><\/div>\n<form action=\"\/wp-json\/wp\/v2\/pages\/709#wpcf7-f705-o1\" method=\"post\" class=\"wpcf7-form init\" aria-label=\"Contact form\" enctype=\"multipart\/form-data\" novalidate=\"novalidate\" data-status=\"init\">\n<div style=\"display: none;\">\n<input type=\"hidden\" name=\"_wpcf7\" value=\"705\" \/>\n<input type=\"hidden\" name=\"_wpcf7_version\" value=\"5.9.3\" \/>\n<input type=\"hidden\" name=\"_wpcf7_locale\" value=\"en_GB\" \/>\n<input type=\"hidden\" name=\"_wpcf7_unit_tag\" value=\"wpcf7-f705-o1\" \/>\n<input type=\"hidden\" name=\"_wpcf7_container_post\" value=\"0\" \/>\n<input type=\"hidden\" name=\"_wpcf7_posted_data_hash\" value=\"\" \/>\n<\/div>\n<style>\n@media only screen and (max-width: 600px) {\n .col{\n float: left;\n width: 100%;\n}\n}\n.col{\n float: left;\n padding: 10px;\n width: 33.3%;\n}\n.col1{\n float: left;\n padding: 10px;\n width: 100%;\n}\n\n.row:after{\n content: \"\";\n display: table;\n clear: both;\n }\n<\/style>\n<p style=\"font-size:30px;color:#0198FF\">PLEASE COMPLETE ALL SECTIONS\n<\/p>\n<p>COPY to be retained in service users note folder with summary sheet and moving and handling plan on front for carer please tick appropriate box and indicate when action is required.\n<\/p>\n<div class=\"row\">\n\t<div class=\"col\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"text-1\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Service User Name\" value=\"\" type=\"text\" name=\"text-1\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"col\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"text-2\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Service User Number\" value=\"\" type=\"text\" name=\"text-2\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"col\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"text-3\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Address\" value=\"\" type=\"text\" name=\"text-3\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"row\">\n\t<div class=\"col1\">\n\t\t<p><label>DOB<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"date-1\"><input class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-required wpcf7-validates-as-date\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"date\" name=\"date-1\" \/><\/span><\/label>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<p style=\"font-size:30px;color:#0198FF\">Environment\n<\/p>\n<div class=\"row\">\n\t<p>Lighting: is External lighting OK?\n\t<\/p>\n\t<div class=\"col\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"radio-1\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"radio-1\" value=\"yes\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"radio-1\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"col\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"text-4\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Actions Required\/Comments\" value=\"\" type=\"text\" name=\"text-4\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"col\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"text-5\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"By Whom?\" value=\"\" type=\"text\" name=\"text-5\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"row\">\n\t<p>Stairways and doors clear and accessible?\n\t<\/p>\n\t<div class=\"col\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"radio-2\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"radio-2\" value=\"yes\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"radio-2\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"col\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"text-6\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Actions Required\/Comments\" value=\"\" type=\"text\" name=\"text-6\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"col\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"text-7\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"By Whom?\" value=\"\" type=\"text\" name=\"text-7\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"row\">\n\t<p>Enough space to perform all tasks safely?\n\t<\/p>\n\t<div class=\"col\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"radio-3\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"radio-3\" value=\"yes\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"radio-3\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"col\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"text-8\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Actions Required\/Comments\" value=\"\" type=\"text\" name=\"text-8\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"col\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"text-9\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"By Whom?\" value=\"\" type=\"text\" name=\"text-9\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"row\">\n\t<p>Furniture and fittings at the right height and position for tasks?\n\t<\/p>\n\t<div class=\"col\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"radio-4\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"radio-4\" value=\"yes\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"radio-4\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"col\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"text-10\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Actions Required\/Comments\" value=\"\" type=\"text\" name=\"text-10\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"col\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"text-11\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"By Whom?\" value=\"\" type=\"text\" name=\"text-11\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"row\">\n\t<p>Any health risk i.e.: sanitation, infestation?\n\t<\/p>\n\t<div class=\"col\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"radio-5\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"radio-5\" value=\"yes\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"radio-5\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"col\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"text-12\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Actions Required\/Comments\" value=\"\" type=\"text\" name=\"text-12\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"col\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"text-13\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"By Whom?\" value=\"\" type=\"text\" name=\"text-13\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"row\">\n\t<p>Heating: is this set at a comfortable level for the service user? (refer to hyperthermia policy)\n\t<\/p>\n\t<div class=\"col\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"radio-6\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"radio-6\" value=\"yes\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"radio-6\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"col\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"text-14\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Actions Required\/Comments\" value=\"\" type=\"text\" name=\"text-14\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"col\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"text-15\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"By Whom?\" value=\"\" type=\"text\" name=\"text-15\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"row\">\n\t<p>Lighting: is internal lighting OK?\n\t<\/p>\n\t<div class=\"col\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"radio-7\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"radio-7\" value=\"yes\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"radio-7\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"col\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"text-16\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Actions Required\/Comments\" value=\"\" type=\"text\" name=\"text-16\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"col\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"text-17\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"By Whom?\" value=\"\" type=\"text\" name=\"text-17\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"row\">\n\t<p>Is flooring in good condition?\n\t<\/p>\n\t<div class=\"col\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"radio-8\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"radio-8\" value=\"yes\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"radio-8\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"col\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"text-18\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Actions Required\/Comments\" value=\"\" type=\"text\" name=\"text-18\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"col\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"text-19\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"By Whom?\" value=\"\" type=\"text\" name=\"text-19\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"row\">\n\t<p>Any loose mats or rugs?\n\t<\/p>\n\t<div class=\"col\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"radio-9\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"radio-9\" value=\"yes\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"radio-9\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"col\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"text-20\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Actions Required\/Comments\" value=\"\" type=\"text\" name=\"text-20\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"col\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"text-21\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"By Whom?\" value=\"\" type=\"text\" name=\"text-21\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"row\">\n\t<p>Are there any awkward steps or changes in floor level?\n\t<\/p>\n\t<div class=\"col\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"radio-10\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"radio-10\" value=\"yes\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"radio-10\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"col\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"text-22\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Actions Required\/Comments\" value=\"\" type=\"text\" name=\"text-22\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"col\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"text-23\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"By Whom?\" value=\"\" type=\"text\" name=\"text-23\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"row\">\n\t<p>Are oxygen cylinders in use?\n\t<\/p>\n\t<div class=\"col\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"radio-11\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"radio-11\" value=\"yes\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"radio-11\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"col\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"text-24\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Actions Required\/Comments\" value=\"\" type=\"text\" name=\"text-24\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"col\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"text-25\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"By Whom?\" value=\"\" type=\"text\" name=\"text-25\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"row\">\n\t<p>Does the service user or significant other smoke?\n\t<\/p>\n\t<div class=\"col\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"radio-12\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"radio-12\" value=\"yes\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"radio-12\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"col\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"text-26\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Actions Required\/Comments\" value=\"\" type=\"text\" name=\"text-26\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"col\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"text-27\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"By Whom?\" value=\"\" type=\"text\" name=\"text-27\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<p style=\"font-size:30px;color:#0198FF\">TASKS\n<\/p>\n<div class=\"row\">\n\t<p>Will the carer require additional training?\n\t<\/p>\n\t<div class=\"col\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"radio-13\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"radio-13\" value=\"yes\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"radio-13\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"col\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"text-28\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Actions Required\/Comments\" value=\"\" type=\"text\" name=\"text-28\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"col\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"text-29\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"By Whom?\" value=\"\" type=\"text\" name=\"text-29\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"row\">\n\t<p>Are there any known infection control issues? Is personal protective equipment required?\n\t<\/p>\n\t<div class=\"col\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"radio-14\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"radio-14\" value=\"yes\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"radio-14\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"col\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"text-30\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Actions Required\/Comments\" value=\"\" type=\"text\" name=\"text-30\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"col\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"text-31\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"By Whom?\" value=\"\" type=\"text\" name=\"text-31\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"row\">\n\t<p>Are the task appropriate for a carer to offer?\n\t<\/p>\n\t<div class=\"col\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"radio-15\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"radio-15\" value=\"yes\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"radio-15\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"col\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"text-32\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Actions Required\/Comments\" value=\"\" type=\"text\" name=\"text-32\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"col\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"text-33\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"By Whom?\" value=\"\" type=\"text\" name=\"text-33\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"row\">\n\t<p>Will the tasks require two carers?\n\t<\/p>\n\t<div class=\"col\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"radio-16\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"radio-16\" value=\"yes\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"radio-16\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"col\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"text-34\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Actions Required\/Comments\" value=\"\" type=\"text\" name=\"text-34\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"col\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"text-35\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"By Whom?\" value=\"\" type=\"text\" name=\"text-35\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"row\">\n\t<p>Any special disposal of waste arrangements needed?\n\t<\/p>\n\t<div class=\"col\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"radio-17\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"radio-17\" value=\"yes\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"radio-17\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"col\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"text-36\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Actions Required\/Comments\" value=\"\" type=\"text\" name=\"text-36\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"col\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"text-37\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"By Whom?\" value=\"\" type=\"text\" name=\"text-37\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"row\">\n\t<p>Soiled laundry?\n\t<\/p>\n\t<div class=\"col\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"radio-18\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"radio-18\" value=\"yes\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"radio-18\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"col\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"text-38\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Actions Required\/Comments\" value=\"\" type=\"text\" name=\"text-38\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"col\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"text-39\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"By Whom?\" value=\"\" type=\"text\" name=\"text-39\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"row\">\n\t<p>Sharps container?\n\t<\/p>\n\t<div class=\"col\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"radio-19\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"radio-19\" value=\"yes\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"radio-19\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"col\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"text-40\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Actions Required\/Comments\" value=\"\" type=\"text\" name=\"text-40\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"col\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"text-41\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"By Whom?\" value=\"\" type=\"text\" name=\"text-41\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"row\">\n\t<p>Medical waste?\n\t<\/p>\n\t<div class=\"col\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"radio-20\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"radio-20\" value=\"yes\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"radio-20\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"col\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"text-42\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Actions Required\/Comments\" value=\"\" type=\"text\" name=\"text-42\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"col\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"text-43\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"By Whom?\" value=\"\" type=\"text\" name=\"text-43\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<p>Any other comments:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"textarea-1\"><textarea cols=\"40\" rows=\"10\" class=\"wpcf7-form-control wpcf7-textarea wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"textarea-1\"><\/textarea><\/span>\n<\/p>\n<p style=\"font-size:30px;color:#0198FF\">ELECTRICAL APPLIANCES\n<\/p>\n<div class=\"row\">\n\t<p>Is the cooker electric?\n\t<\/p>\n\t<div class=\"col\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"radio-21\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"radio-21\" value=\"yes\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"radio-21\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"col\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"text-44\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Actions Required\/Comments\" value=\"\" type=\"text\" name=\"text-44\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"col\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"text-45\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"By Whom?\" value=\"\" type=\"text\" name=\"text-45\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"row\">\n\t<p>Is the heating electric?\n\t<\/p>\n\t<div class=\"col\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"radio-22\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"radio-22\" value=\"yes\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"radio-22\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"col\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"text-46\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Actions Required\/Comments\" value=\"\" type=\"text\" name=\"text-46\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"col\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"text-47\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"By Whom?\" value=\"\" type=\"text\" name=\"text-47\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"row\">\n\t<p>Are there any obvious faults?\n\t<\/p>\n\t<div class=\"col\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"radio-23\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"radio-23\" value=\"yes\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"radio-23\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"col\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"text-48\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Actions Required\/Comments\" value=\"\" type=\"text\" name=\"text-48\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"col\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"text-49\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"By Whom?\" value=\"\" type=\"text\" name=\"text-49\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"row\">\n\t<p>Electrical appliances visually checked?\n\t<\/p>\n\t<div class=\"col\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"radio-24\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"radio-24\" value=\"yes\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"radio-24\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"col\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"text-50\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Actions Required\/Comments\" value=\"\" type=\"text\" name=\"text-50\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"col\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"text-51\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"By Whom?\" value=\"\" type=\"text\" name=\"text-51\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"row\">\n\t<p>Do sockets, plugs wiring and installation look clean and well maintained?\n\t<\/p>\n\t<div class=\"col\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"radio-25\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"radio-25\" value=\"yes\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"radio-25\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"col\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"text-52\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Actions Required\/Comments\" value=\"\" type=\"text\" name=\"text-52\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"col\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"text-53\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"By Whom?\" value=\"\" type=\"text\" name=\"text-53\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"row\">\n\t<p>Are there any trailing cables or cables under carpet?\n\t<\/p>\n\t<div class=\"col\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"radio-26\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"radio-26\" value=\"yes\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"radio-26\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"col\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"text-54\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Actions Required\/Comments\" value=\"\" type=\"text\" name=\"text-54\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"col\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"text-55\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"By Whom?\" value=\"\" type=\"text\" name=\"text-55\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<p>Any other comments please state:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"textarea-2\"><textarea cols=\"40\" rows=\"10\" class=\"wpcf7-form-control wpcf7-textarea wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"textarea-2\"><\/textarea><\/span>\n<\/p>\n<p style=\"font-size:30px;color:#0198FF\">APPLIANCE\n<\/p>\n<p>Use the table below to record visual checks with a tick if satisfactory\n<\/p>\n<div class=\"row\">\n\t<p>Washing machine\n\t<\/p>\n\t<div class=\"col1\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"checkbox-1\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"CONDITION\" \/><span class=\"wpcf7-list-item-label\">CONDITION<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"PLUG\" \/><span class=\"wpcf7-list-item-label\">PLUG<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"SOCKET\" \/><span class=\"wpcf7-list-item-label\">SOCKET<\/span><\/span><\/span><\/span>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"row\">\n\t<p>iron\n\t<\/p>\n\t<div class=\"col1\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"checkbox-2\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"checkbox-2[]\" value=\"CONDITION\" \/><span class=\"wpcf7-list-item-label\">CONDITION<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"checkbox-2[]\" value=\"PLUG\" \/><span class=\"wpcf7-list-item-label\">PLUG<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"checkbox-2[]\" value=\"SOCKET\" \/><span class=\"wpcf7-list-item-label\">SOCKET<\/span><\/span><\/span><\/span>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"row\">\n\t<p>Toaster\n\t<\/p>\n\t<div class=\"col1\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"checkbox-3\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"checkbox-3[]\" value=\"CONDITION\" \/><span class=\"wpcf7-list-item-label\">CONDITION<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"checkbox-3[]\" value=\"PLUG\" \/><span class=\"wpcf7-list-item-label\">PLUG<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"checkbox-3[]\" value=\"SOCKET\" \/><span class=\"wpcf7-list-item-label\">SOCKET<\/span><\/span><\/span><\/span>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"row\">\n\t<p>Vacuum cleaner\n\t<\/p>\n\t<div class=\"col1\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"checkbox-4\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"checkbox-4[]\" value=\"CONDITION\" \/><span class=\"wpcf7-list-item-label\">CONDITION<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"checkbox-4[]\" value=\"PLUG\" \/><span class=\"wpcf7-list-item-label\">PLUG<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"checkbox-4[]\" value=\"SOCKET\" \/><span class=\"wpcf7-list-item-label\">SOCKET<\/span><\/span><\/span><\/span>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"row\">\n\t<p>Electric fire\n\t<\/p>\n\t<div class=\"col1\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"checkbox-5\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"checkbox-5[]\" value=\"CONDITION\" \/><span class=\"wpcf7-list-item-label\">CONDITION<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"checkbox-5[]\" value=\"PLUG\" \/><span class=\"wpcf7-list-item-label\">PLUG<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"checkbox-5[]\" value=\"SOCKET\" \/><span class=\"wpcf7-list-item-label\">SOCKET<\/span><\/span><\/span><\/span>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"row\">\n\t<p>Television\n\t<\/p>\n\t<div class=\"col1\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"checkbox-6\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"checkbox-6[]\" value=\"CONDITION\" \/><span class=\"wpcf7-list-item-label\">CONDITION<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"checkbox-6[]\" value=\"PLUG\" \/><span class=\"wpcf7-list-item-label\">PLUG<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"checkbox-6[]\" value=\"SOCKET\" \/><span class=\"wpcf7-list-item-label\">SOCKET<\/span><\/span><\/span><\/span>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"row\">\n\t<p>microwave\n\t<\/p>\n\t<div class=\"col1\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"checkbox-7\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"checkbox-7[]\" value=\"CONDITION\" \/><span class=\"wpcf7-list-item-label\">CONDITION<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"checkbox-7[]\" value=\"PLUG\" \/><span class=\"wpcf7-list-item-label\">PLUG<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"checkbox-7[]\" value=\"SOCKET\" \/><span class=\"wpcf7-list-item-label\">SOCKET<\/span><\/span><\/span><\/span>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"row\">\n\t<p>Kettle\n\t<\/p>\n\t<div class=\"col1\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"checkbox-8\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"checkbox-8[]\" value=\"CONDITION\" \/><span class=\"wpcf7-list-item-label\">CONDITION<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"checkbox-8[]\" value=\"PLUG\" \/><span class=\"wpcf7-list-item-label\">PLUG<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"checkbox-8[]\" value=\"SOCKET\" \/><span class=\"wpcf7-list-item-label\">SOCKET<\/span><\/span><\/span><\/span>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"row\">\n\t<p>Electric blanket\n\t<\/p>\n\t<div class=\"col1\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"checkbox-9\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"checkbox-9[]\" value=\"CONDITION\" \/><span class=\"wpcf7-list-item-label\">CONDITION<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"checkbox-9[]\" value=\"PLUG\" \/><span class=\"wpcf7-list-item-label\">PLUG<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"checkbox-9[]\" value=\"SOCKET\" \/><span class=\"wpcf7-list-item-label\">SOCKET<\/span><\/span><\/span><\/span>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<p>Any actions (please specify)<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"textarea-3\"><textarea cols=\"40\" rows=\"10\" class=\"wpcf7-form-control wpcf7-textarea wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"textarea-3\"><\/textarea><\/span>\n<\/p>\n<p style=\"font-size:30px;color:#0198FF\">GAS APPLIANCES\n<\/p>\n<div class=\"row\">\n\t<p>Is the cooker gas?\n\t<\/p>\n\t<div class=\"col\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"radio-27\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"radio-27\" value=\"yes\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"radio-27\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"col\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"text-56\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Actions Required\/Comments\" value=\"\" type=\"text\" name=\"text-56\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"col\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"text-57\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"By Whom?\" value=\"\" type=\"text\" name=\"text-57\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"row\">\n\t<p>Are there any obvious faults?\n\t<\/p>\n\t<div class=\"col\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"radio-28\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"radio-28\" value=\"yes\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"radio-28\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"col\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"text-58\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Actions Required\/Comments\" value=\"\" type=\"text\" name=\"text-58\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"col\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"text-59\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"By Whom?\" value=\"\" type=\"text\" name=\"text-59\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"row\">\n\t<p>Does it self ignite?\n\t<\/p>\n\t<div class=\"col\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"radio-29\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"radio-29\" value=\"yes\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"radio-29\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"col\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"text-60\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Actions Required\/Comments\" value=\"\" type=\"text\" name=\"text-60\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"col\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"text-61\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"By Whom?\" value=\"\" type=\"text\" name=\"text-61\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"row\">\n\t<p>If yes is that working?\n\t<\/p>\n\t<div class=\"col\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"radio-30\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"radio-30\" value=\"yes\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"radio-30\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"col\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"text-62\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Actions Required\/Comments\" value=\"\" type=\"text\" name=\"text-62\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"col\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"text-63\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"By Whom?\" value=\"\" type=\"text\" name=\"text-63\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"row\">\n\t<p>Is there a gas fire?\n\t<\/p>\n\t<div class=\"col\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"radio-31\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"radio-31\" value=\"yes\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"radio-31\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"col\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"text-64\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Actions Required\/Comments\" value=\"\" type=\"text\" name=\"text-64\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"col\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"text-65\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"By Whom?\" value=\"\" type=\"text\" name=\"text-65\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"row\">\n\t<p>Is there gas central heating\n\t<\/p>\n\t<div class=\"col\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"radio-32\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"radio-32\" value=\"yes\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"radio-32\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"col\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"text-66\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Actions Required\/Comments\" value=\"\" type=\"text\" name=\"text-66\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"col\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"text-67\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"By Whom?\" value=\"\" type=\"text\" name=\"text-67\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"row\">\n\t<p>Does the service user have a gas maintenance plan\/contract?\n\t<\/p>\n\t<div class=\"col\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"radio-33\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"radio-33\" value=\"yes\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"radio-33\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"col\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"text-68\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Actions Required\/Comments\" value=\"\" type=\"text\" name=\"text-68\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"col\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"text-69\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"By Whom?\" value=\"\" type=\"text\" name=\"text-69\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"row\">\n\t<p>Are there any signs of carbon monoxide leaking e.g soot around the boiler or fire?\n\t<\/p>\n\t<div class=\"col\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"radio-34\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"radio-34\" value=\"yes\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"radio-34\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"col\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"text-70\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Actions Required\/Comments\" value=\"\" type=\"text\" name=\"text-70\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"col\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"text-71\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"By Whom?\" value=\"\" type=\"text\" name=\"text-71\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"row\">\n\t<p>Is there a working carbon monoxide detector?\n\t<\/p>\n\t<div class=\"col\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"radio-35\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"radio-35\" value=\"yes\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"radio-35\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"col\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"text-72\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Actions Required\/Comments\" value=\"\" type=\"text\" name=\"text-72\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"col\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"text-73\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"By Whom?\" value=\"\" type=\"text\" name=\"text-73\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<p>Any other comments:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"textarea-4\"><textarea cols=\"40\" rows=\"10\" class=\"wpcf7-form-control wpcf7-textarea wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"textarea-4\"><\/textarea><\/span>\n<\/p>\n<p style=\"font-size:30px;color:#0198FF\">WATER\n<\/p>\n<div class=\"row\">\n\t<div class=\"col1\">\n\t\t<p><label>Where is the stopcock located?<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"text-74\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"text-74\" \/><\/span><\/label>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<p style=\"font-size:30px;color:#0198FF\">OPEN FIRES\n<\/p>\n<div class=\"row\">\n\t<p>Is there an open fire?\n\t<\/p>\n\t<div class=\"col\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"radio-36\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"radio-36\" value=\"yes\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"radio-36\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"col\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"text-75\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Actions Required\/Comments\" value=\"\" type=\"text\" name=\"text-75\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"col\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"text-76\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"By Whom?\" value=\"\" type=\"text\" name=\"text-76\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"row\">\n\t<p>Coal burning?\n\t<\/p>\n\t<div class=\"col\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"radio-37\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"radio-37\" value=\"yes\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"radio-37\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"col\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"text-77\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Actions Required\/Comments\" value=\"\" type=\"text\" name=\"text-77\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"col\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"text-78\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"By Whom?\" value=\"\" type=\"text\" name=\"text-78\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"row\">\n\t<p>Wood burning?\n\t<\/p>\n\t<div class=\"col\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"radio-38\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"radio-38\" value=\"yes\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"radio-38\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"col\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"text-79\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Actions Required\/Comments\" value=\"\" type=\"text\" name=\"text-79\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"col\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"text-80\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"By Whom?\" value=\"\" type=\"text\" name=\"text-80\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"row\">\n\t<p>Is there a fire guard?\n\t<\/p>\n\t<div class=\"col\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"radio-39\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"radio-39\" value=\"yes\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"radio-39\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"col\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"text-81\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Actions Required\/Comments\" value=\"\" type=\"text\" name=\"text-81\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"col\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"text-82\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"By Whom?\" value=\"\" type=\"text\" name=\"text-82\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"row\">\n\t<p>Are all fires clear of furniture, curtains, and bedclothes?\n\t<\/p>\n\t<div class=\"col\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"radio-40\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"radio-40\" value=\"yes\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"radio-40\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"col\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"text-83\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Actions Required\/Comments\" value=\"\" type=\"text\" name=\"text-83\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"col\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"text-84\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"By Whom?\" value=\"\" type=\"text\" name=\"text-84\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"row\">\n\t<p>Is fuel stored where it can be safely assessed?\n\t<\/p>\n\t<div class=\"col\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"radio-41\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"radio-41\" value=\"yes\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"radio-41\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"col\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"text-85\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Actions Required\/Comments\" value=\"\" type=\"text\" name=\"text-85\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"col\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"text-86\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"By Whom?\" value=\"\" type=\"text\" name=\"text-86\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<p>Any other comments:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"textarea-5\"><textarea cols=\"40\" rows=\"10\" class=\"wpcf7-form-control wpcf7-textarea wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"textarea-5\"><\/textarea><\/span>\n<\/p>\n<p style=\"font-size:30px;color:#0198FF\">SIGNIFICANT OTHERS\n<\/p>\n<div class=\"row\">\n\t<p>If there are other people in the working environment are there concerns for safety?\n\t<\/p>\n\t<div class=\"col\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"radio-42\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"radio-42\" value=\"yes\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"radio-42\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"col\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"text-87\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Actions Required\/Comments\" value=\"\" type=\"text\" name=\"text-87\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"col\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"text-88\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"By Whom?\" value=\"\" type=\"text\" name=\"text-88\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"row\">\n\t<p>Is the significant other designated as a second care worker for moving and handling?\n\t<\/p>\n\t<div class=\"col\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"radio-43\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"radio-43\" value=\"yes\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"radio-43\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"col\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"text-89\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Actions Required\/Comments\" value=\"\" type=\"text\" name=\"text-89\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"col\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"text-90\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"By Whom?\" value=\"\" type=\"text\" name=\"text-90\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"row\">\n\t<p>Are they trained to do so?\n\t<\/p>\n\t<div class=\"col\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"radio-44\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"radio-44\" value=\"yes\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"radio-44\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"col\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"text-91\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Actions Required\/Comments\" value=\"\" type=\"text\" name=\"text-91\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"col\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"text-92\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"By Whom?\" value=\"\" type=\"text\" name=\"text-92\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"row\">\n\t<p>If yes do we have a copy of certificate dated within the last 24 months?\n\t<\/p>\n\t<div class=\"col\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"radio-45\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"radio-45\" value=\"yes\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"radio-45\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"col\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"text-93\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Actions Required\/Comments\" value=\"\" type=\"text\" name=\"text-93\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"col\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"text-94\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"By Whom?\" value=\"\" type=\"text\" name=\"text-94\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"row\">\n\t<p>Is there any potential for violent\/aggressive behaviour from the service user or the significant other?\n\t<\/p>\n\t<div class=\"col\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"radio-46\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"radio-46\" value=\"yes\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"radio-46\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"col\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"text-95\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Actions Required\/Comments\" value=\"\" type=\"text\" name=\"text-95\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"col\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"text-96\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"By Whom?\" value=\"\" type=\"text\" name=\"text-96\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<p>Any other comments:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"textarea-6\"><textarea cols=\"40\" rows=\"10\" class=\"wpcf7-form-control wpcf7-textarea wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"textarea-6\"><\/textarea><\/span>\n<\/p>\n<p style=\"font-size:30px;color:#0198FF\">PETS\n<\/p>\n<div class=\"row\">\n\t<p>Are there any domestic animals in the home?\n\t<\/p>\n\t<div class=\"col\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"radio-47\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"radio-47\" value=\"yes\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"radio-47\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"col\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"text-97\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Actions Required\/Comments\" value=\"\" type=\"text\" name=\"text-97\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"col\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"text-98\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"By Whom?\" value=\"\" type=\"text\" name=\"text-98\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"row\">\n\t<p>If yes, are they under control?\n\t<\/p>\n\t<div class=\"col\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"radio-48\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"radio-48\" value=\"yes\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"radio-48\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"col\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"text-99\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Actions Required\/Comments\" value=\"\" type=\"text\" name=\"text-99\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"col\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"text-100\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"By Whom?\" value=\"\" type=\"text\" name=\"text-100\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"row\">\n\t<p>Has the pet ever injured anyone?\n\t<\/p>\n\t<div class=\"col\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"radio-49\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"radio-49\" value=\"yes\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"radio-49\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"col\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"text-101\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Actions Required\/Comments\" value=\"\" type=\"text\" name=\"text-101\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"col\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"text-102\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"By Whom?\" value=\"\" type=\"text\" name=\"text-102\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"row\">\n\t<p>Is the pet(s) house trained?\n\t<\/p>\n\t<div class=\"col\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"radio-50\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"radio-50\" value=\"yes\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"radio-50\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"col\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"text-103\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Actions Required\/Comments\" value=\"\" type=\"text\" name=\"text-103\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"col\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"text-104\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"By Whom?\" value=\"\" type=\"text\" name=\"text-104\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<p>Any other comments:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"textarea-7\"><textarea cols=\"40\" rows=\"10\" class=\"wpcf7-form-control wpcf7-textarea wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"textarea-7\"><\/textarea><\/span>\n<\/p>\n<p style=\"font-size:30px;color:#0198FF\">FIRE SAFETY\n<\/p>\n<div class=\"row\">\n\t<p>Does the service user have smoke alarms?\n\t<\/p>\n\t<div class=\"col\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"radio-51\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"radio-51\" value=\"yes\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"radio-51\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"col\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"text-105\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Actions Required\/Comments\" value=\"\" type=\"text\" name=\"text-105\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"col\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"text-106\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"By Whom?\" value=\"\" type=\"text\" name=\"text-106\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"row\">\n\t<p>If yes has the service user confirmed they are working?\n\t<\/p>\n\t<div class=\"col\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"radio-52\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"radio-52\" value=\"yes\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"radio-52\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"col\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"text-107\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Actions Required\/Comments\" value=\"\" type=\"text\" name=\"text-107\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"col\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"text-108\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"By Whom?\" value=\"\" type=\"text\" name=\"text-108\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"row\">\n\t<p>If no, have you advised the service user of the importance of smoke alarms?\n\t<\/p>\n\t<div class=\"col\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"radio-53\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"radio-53\" value=\"yes\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"radio-53\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"col\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"text-109\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Actions Required\/Comments\" value=\"\" type=\"text\" name=\"text-109\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"col\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"text-110\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"By Whom?\" value=\"\" type=\"text\" name=\"text-110\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"row\">\n\t<p>Are fire or heaters used for drying clothes?\n\t<\/p>\n\t<div class=\"col\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"radio-54\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"radio-54\" value=\"yes\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"radio-54\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"col\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"text-111\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Actions Required\/Comments\" value=\"\" type=\"text\" name=\"text-111\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"col\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"text-112\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"By Whom?\" value=\"\" type=\"text\" name=\"text-112\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"row\">\n\t<p>Anything in the home to indicate a higher than normal risk of fire eg; smoking, oxygen, piles of paper, chip pans etc?\n\t<\/p>\n\t<div class=\"col\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"radio-55\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"radio-55\" value=\"yes\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"radio-55\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"col\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"text-113\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Actions Required\/Comments\" value=\"\" type=\"text\" name=\"text-113\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"col\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"text-114\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"By Whom?\" value=\"\" type=\"text\" name=\"text-114\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"row\">\n\t<p>Is there more than one way to evacuate the building in an emergency?\n\t<\/p>\n\t<div class=\"col\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"radio-56\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"radio-56\" value=\"yes\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"radio-56\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"col\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"text-115\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Actions Required\/Comments\" value=\"\" type=\"text\" name=\"text-115\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"col\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"text-116\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"By Whom?\" value=\"\" type=\"text\" name=\"text-116\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"row\">\n\t<p>Are non essential appliances switched off at night?\n\t<\/p>\n\t<div class=\"col\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"radio-57\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"radio-57\" value=\"yes\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"radio-57\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"col\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"text-117\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Actions Required\/Comments\" value=\"\" type=\"text\" name=\"text-117\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"col\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"text-118\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"By Whom?\" value=\"\" type=\"text\" name=\"text-118\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"row\">\n\t<p>Does the service user have a telephone?\n\t<\/p>\n\t<div class=\"col\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"radio-58\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"radio-58\" value=\"yes\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"radio-58\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"col\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"text-119\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Actions Required\/Comments\" value=\"\" type=\"text\" name=\"text-119\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"col\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"text-120\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"By Whom?\" value=\"\" type=\"text\" name=\"text-120\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"row\">\n\t<p>Is the service user linked to a community alarm?\n\t<\/p>\n\t<div class=\"col\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"radio-59\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"radio-59\" value=\"yes\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"radio-59\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"col\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"text-121\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Actions Required\/Comments\" value=\"\" type=\"text\" name=\"text-121\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"col\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"text-122\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"By Whom?\" value=\"\" type=\"text\" name=\"text-122\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"row\">\n\t<p>Does the service user have access to a garden?\n\t<\/p>\n\t<div class=\"col\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"radio-60\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"radio-60\" value=\"yes\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"radio-60\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"col\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"text-123\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Actions Required\/Comments\" value=\"\" type=\"text\" name=\"text-123\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"col\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"text-124\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"By Whom?\" value=\"\" type=\"text\" name=\"text-124\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<p>Any other comments:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"textarea-8\"><textarea cols=\"40\" rows=\"10\" class=\"wpcf7-form-control wpcf7-textarea wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"textarea-8\"><\/textarea><\/span>\n<\/p>\n<p style=\"font-size:30px;color:#0198FF\">FINANCE\n<\/p>\n<div class=\"row\">\n\t<p>Can the service user sign documents including time sheets?\n\t<\/p>\n\t<div class=\"col\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"radio-61\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"radio-61\" value=\"yes\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"radio-61\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"col\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"text-125\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Actions Required\/Comments\" value=\"\" type=\"text\" name=\"text-125\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"col\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"text-126\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"By Whom?\" value=\"\" type=\"text\" name=\"text-126\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"row\">\n\t<p>Does the service user require assistance with finance?\n\t<\/p>\n\t<div class=\"col\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"radio-62\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"radio-62\" value=\"yes\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"radio-62\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"col\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"text-127\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Actions Required\/Comments\" value=\"\" type=\"text\" name=\"text-127\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"col\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"text-128\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"By Whom?\" value=\"\" type=\"text\" name=\"text-128\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"row\">\n\t<p>If yes \u2013 pension or benefit?\n\t<\/p>\n\t<div class=\"col\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"radio-63\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"radio-63\" value=\"yes\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"radio-63\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"col\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"text-129\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Actions Required\/Comments\" value=\"\" type=\"text\" name=\"text-129\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"col\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"text-130\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"By Whom?\" value=\"\" type=\"text\" name=\"text-130\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"row\">\n\t<p>If yes paying for shopping?\n\t<\/p>\n\t<div class=\"col\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"radio-64\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"radio-64\" value=\"yes\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"radio-64\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"col\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"text-131\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Actions Required\/Comments\" value=\"\" type=\"text\" name=\"text-131\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"col\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"text-132\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"By Whom?\" value=\"\" type=\"text\" name=\"text-132\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"row\">\n\t<p>If yes bill payment?\n\t<\/p>\n\t<div class=\"col\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"radio-65\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"radio-65\" value=\"yes\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"radio-65\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"col\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"text-133\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Actions Required\/Comments\" value=\"\" type=\"text\" name=\"text-133\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"col\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"text-134\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"By Whom?\" value=\"\" type=\"text\" name=\"text-134\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<p>Please give more details:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"textarea-9\"><textarea cols=\"40\" rows=\"10\" class=\"wpcf7-form-control wpcf7-textarea wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"textarea-9\"><\/textarea><\/span>\n<\/p>\n<p style=\"font-size:30px;color:#0198FF\">EXTERNAL ENVIROMENT\n<\/p>\n<div class=\"row\">\n\t<p>Does the locality pose a risk?\n\t<\/p>\n\t<div class=\"col\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"radio-66\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"radio-66\" value=\"yes\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"radio-66\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"col\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"text-135\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Actions Required\/Comments\" value=\"\" type=\"text\" name=\"text-135\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"col\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"text-136\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"By Whom?\" value=\"\" type=\"text\" name=\"text-136\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"row\">\n\t<p>Are there any obvious hazards in the external environment?\n\t<\/p>\n\t<div class=\"col\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"radio-67\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"radio-67\" value=\"yes\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"radio-67\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"col\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"text-137\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Actions Required\/Comments\" value=\"\" type=\"text\" name=\"text-137\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"col\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"text-138\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"By Whom?\" value=\"\" type=\"text\" name=\"text-138\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"row\">\n\t<p>Is external access to the property clear \u2013 eg no overgrown or hazards?\n\t<\/p>\n\t<div class=\"col\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"radio-68\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"radio-68\" value=\"yes\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"radio-68\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"col\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"text-139\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Actions Required\/Comments\" value=\"\" type=\"text\" name=\"text-139\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"col\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"text-140\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"By Whom?\" value=\"\" type=\"text\" name=\"text-140\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"row\">\n\t<p>Does the service user leave their home during care worker visits?\n\t<\/p>\n\t<div class=\"col\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"radio-69\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"radio-69\" value=\"yes\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"radio-69\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"col\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"text-141\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Actions Required\/Comments\" value=\"\" type=\"text\" name=\"text-141\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"col\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"text-142\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"By Whom?\" value=\"\" type=\"text\" name=\"text-142\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"row\">\n\t<p>If yes is it appropriate for the care worker to transport the service user?\n\t<\/p>\n\t<div class=\"col\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"radio-70\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"radio-70\" value=\"yes\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"radio-70\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"col\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"text-143\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Actions Required\/Comments\" value=\"\" type=\"text\" name=\"text-143\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"col\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"text-144\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"By Whom?\" value=\"\" type=\"text\" name=\"text-144\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"row\">\n\t<p>Is the service user to be transported by the care worker?\n\t<\/p>\n\t<div class=\"col\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"radio-71\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"radio-71\" value=\"yes\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"radio-71\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"col\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"text-145\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Actions Required\/Comments\" value=\"\" type=\"text\" name=\"text-145\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"col\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"text-146\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"By Whom?\" value=\"\" type=\"text\" name=\"text-146\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"row\">\n\t<p>If yes is it appropriate for the care worker to transport the service user?\n\t<\/p>\n\t<div class=\"col\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"radio-72\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"radio-72\" value=\"yes\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"radio-72\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"col\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"text-147\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Actions Required\/Comments\" value=\"\" type=\"text\" name=\"text-147\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"col\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"text-148\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"By Whom?\" value=\"\" type=\"text\" name=\"text-148\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<p>Any other comments:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"textarea-10\"><textarea cols=\"40\" rows=\"10\" class=\"wpcf7-form-control wpcf7-textarea wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"textarea-10\"><\/textarea><\/span>\n<\/p>\n<div class=\"row\">\n\t<div class=\"col1\">\n\t\t<p><label>Supervisor:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"text-149\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"text-149\" \/><\/span><\/label>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"row\">\n\t<div class=\"col1\">\n\t\t<p><label><br \/>\nSupervisors Signature<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"file-1\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-file\" accept=\"audio\/*,video\/*,image\/*\" aria-invalid=\"false\" type=\"file\" name=\"file-1\" \/><\/span><\/label>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"row\">\n\t<div class=\"col1\">\n\t\t<p><label>Date<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"date-2\"><input class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-required wpcf7-validates-as-date\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"date\" name=\"date-2\" \/><\/span><\/label>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<p><input class=\"wpcf7-form-control wpcf7-submit has-spinner\" type=\"submit\" value=\"Send\" \/>\n<\/p><div class=\"wpcf7-response-output\" aria-hidden=\"true\"><\/div>\n<\/form>\n<\/div>\n\n","protected":false},"excerpt":{"rendered":"","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"footnotes":""},"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v14.4.1 - https:\/\/yoast.com\/wordpress\/plugins\/seo\/ -->\n<title>Service User Risk Assessment - DJ Care Services<\/title>\n<meta name=\"robots\" content=\"index, follow\" \/>\n<meta name=\"googlebot\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<meta name=\"bingbot\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"http:\/\/djcareservices.com\/service-user-assessment\/\" \/>\n<meta property=\"og:locale\" content=\"en_GB\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"Service User Risk 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