Environmental Safety Self-Assessment Environmental Safety Self-Assessment Form for Discharged Clients FAILURE TO REPORT ON THE HIGHLIGHTED MANDATORY COMPONENTS LISTED ON THIS FORM WILL RESULT IN TERMINATION OF THE RENTAL SUBSIDY WITH NO ABILITY TO REINSTATE IT. Client Name(Required) Phone Number(Required) Address(Required) City / Province(Required) Postal Code(Required) Smoke Detector / CO Detector (if installed):(Required) Yes No *If you do not have a working smoke detector, contact your landlord immediately and report. Clear route of egress from unit:(Required) Yes No Safe electrical practices in use:(Required) Yes No Fire evacuation plan in place:(Required) Yes No Any pest issues (Bedbugs/Cockroaches):(Required) Yes No *Any pest issues, contact your landlord immediately and report.Signature Date MUST SIGN AND DATE. FAILURE TO REPORT ON THE HIGHLIGHTED MANDATORY COMPONENTS LISTED ON THIS FORM WILL RESULT IN TERMINATION OF THE RENTAL SUBSIDY WITH NO ABILITY TO REINSTATE IT.
