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?
Do you have working smoke detectors installed on every level of your home?
When did you last test your smoke detectors?
Please rate the overall fire safety of your home.
Which of the following fire safety equipment do you have at home? (Select all that apply)
Other

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

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