Home Fire Safety Survey

Home Fire Safety Survey
Help assess your home's fire safety by answering the following questions.
Full Name*
First NameLast Name
Email Address*
example@example.com
Home Address*
Street Address
Street Address Line 2
CityState / ProvincePostal / Zip Code
How many people live in your household?*
YesNoSome, but not all levels
When did you last test your smoke detectors?*
Please rate the overall fire safety of your home.*
Fire extinguisher(s)Fire blanketFire escape ladderNone of the aboveOther

Fire Safety Practices at Home*

Rows	Yes	No	Not Sure
We have a family fire escape plan
We practice fire drills at least once a year
Flammable items are kept away from heat sources
Electrical cords are checked regularly for damage