Child Safety Survey

How old is your child?*

0 - 12 months 1 - 2 years Above 2 years

Are safety gates fixed at the top and bottom of the stairs?*

Yes No N/A

Does your bathtub and bathroom floor have non-slippery mats?*

Yes No N/A

Do you avoid giving your infant or toddler hard candy, popcorn, raw carrots, and grapes?*

Yes No N/A

Do you avoid sleeping next to your infants?*

Yes No N/A

If there is a toddler in the home, is the toilet cover secured?*

Yes No N/A

Do you empty any source of water such as filled buckets and inflatable swimming pools directly after use?*

Yes No N/A