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CMHA Windsor-Essex County

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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.

Smoke Detector / CO Detector (if installed):(Required)
*If you do not have a working smoke detector, contact your landlord immediately and report.
Clear route of egress from unit:(Required)
Safe electrical practices in use:(Required)
Fire evacuation plan in place:(Required)
Any pest issues (Bedbugs/Cockroaches):(Required)
*Any pest issues, contact your landlord immediately and report.
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.