1. Do you put the crib side up whenever you leave your 

Always Sometimes Never 

baby in the crib? 

2. Do you leave the baby alone on tables or beds, even 

Frequently Occasionally Never 

for a brief moment? 

3. Do you leave the baby alone at home? 

Frequently Occasionally Never 

4. Do you keep plastic wrappers, plastic bags, and 

Always Sometimes Never 

balloons away from your children? 

5. Does your child wear a pacifier or jewelry around his Frequently Occasionally Never 

or her neck? 

6. Does your child play with small objects such as beads or nuts? Frequently Occasionally Never 

7. Are any of your baby-sitters younger than 13 years? 

Yes Don’t know No 

8. How frequently is the heating system checked where you live? Never At least once a year Every few years 

9. Are your operable window guards in place? All windows Some windows None 

10. Do you ever place your baby in an infant walker? 

Yes No 

11. Does anyone in your home ever smoke? 

Frequently Occasionally Never 

12. Do you have a plan for escape from your home in the event Yes No 

of a fire? 

13. Do you have working fire extinguishers in your home? Yes Don’t know No 

14. Do you have working smoke alarms in your home? Yes No 

15. Do you ever drink or carry hot liquids when holding your baby? Frequently Occasionally Never 

16. Do you ever use woodstoves or kerosene heaters? Yes No 

17. Do you leave the baby alone in or near a tub, pail of water, Frequently Occasionally Never 

or toilet, even for a brief moment? 

18. Do you have a pool or hot tub where you live? Yes No 

19. Do you use a car safety seat in the car on every trip at all times? Yes No 

20. Does your car have a passenger air bag? Yes No 

21. Where do you place your child’s car safety seat in the car? Front Rear Front or rear 

22. Does your child ride on your bicycle with you? Frequently Occasionally Never 

23. Is there a gun in your home or the home where your child plays Yes Don’t know No 

or is cared for?