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Fire Safety Survey

This form should be completed by the applicant as part of the home approval process. Please upload a Diagram of Escape Routes from your Home.

Caseworker

 

Caregiver Information

 
Telephone (Does the home have a working telephone?):
Smoke Detector (Is there a working battery Operated smoke detector located on each level of the home?):
Escape Rooms (Are there at least two ways of escape from each bedroom?):
If one way of escape from the bedroom is through a window, is that window large enough to allow ready exit for every child in the home?:
Are the ways of escape from each bedroom free of object that would prevent easy exit?:
Is there an organized plan for getting all individuals safely and quickly out of the home in the event of a fire?:
Flammables (Are highly flammable items kept away from heating and cooking units?):
Address (Can you clearly see the house number from the street?):
 
   
Enter security code:
 Security code