Appendix B: CRR Home Safety Visit Questionnaire
Download the CRR Home Safety Questionnaire (PDF)
FEMA Assistance to Firefighters Grant Program
Revisit? Check box if this is a revisit to a home for which a form was previously submitted (e.g., when no one was home at first).
Date of visit: ___________________________________
Time home safety visit starts:____________________
Name of occupant:_________________________________
Home Phone:_______________________________________
Street Address: __________________________________
Apt No.: _________________________________________
City and state: __________________________________
ZIP: _____________________________________________
Please do not leave any questions blank
If the answer to a question is “0” or “None,” enter “0”
- Type of home
Detached house; Mobile home; Duplex/townhouse; Multifamily; Other
- If entry to residence was not possible, why not? (check primary reason only)
No one home; Occupant refused entry (Why? Fill in.) ________________________; Minor only; Language Barrier; Other; Vacant home/lot
- Names of fire department representatives making the visit:
- Positions of fire department representatives making the visit (check all that apply)
Firefighter; Social worker; Health care worker; Prevention Bureau; Community volunteer; Other ____________________
Situation Found
- Number of working smoke alarms (excluding private fire alarm system)
- Number of non-working smoke alarms (excluding private fire alarm system)
- Was a private fire alarm system present? (Do not test)
If yes:- Number of smoke alarms in the private fire alarm system
- Did the private fire alarm system appear to be working?
Installations Made
- Type and quantity of alarm(s) installed (fill in the quantity)
- First Alert Photoelectric Smoke Alarm
- Kidde Ionization Smoke Alarms
- Gentex Smoke Alarm and Strobe
- LifeTone Bedside Alarm/Clock/Bedshaker
- Other (specify) _____________
- Total number of alarms installed
- If zero alarms were installed, why?
- Number of working smoke alarms replaced due to age
- Number of non-working smoke alarms whose batteries were replaced (if any)
- Number of working smoke alarms whose batteries were replaced (if any)
- Total number of working smoke alarms at the end of the visit
- Did the home end up with the number of working smoke alarms required by code?
If no:- Why not?
- Not enough time during visit
- Not enough smoke alarms
- Occupant refused (Why? Fill in.) ________________________________
- Was the occupant advised of the number of smoke alarms required to meet code?
- Why not?
Education Provided
- Occupant instructed on (check all that apply):
- No instruction provided
- Residential sprinklers
- Cooking safety
- Heating safety
- CO safety
- Smoking safety
- Candle safety
- Smoke alarms
- Escape planning
- Other___________________
- Ask occupant: Do you have a fire escape plan?
If yes:- Was the fire escape plan practiced in the last year?
- Where is your meeting place? ( Credible site / Not credible site)
- Occupant given written materials on:
- No written materials left
- Residential sprinklers
- Cooking safety
- Heating safety
- CO safety
- Smoking safety
- Candle safety
- Smoke alarms
- Escape planning
- Other ____________________
Demographics (ask resident)
- Do you own or rent your home?
- How many people live in your home?
- How many children living in your home are under age 5?
- How many people living in your home are over age 65?
- How many people living in your home are physically or mentally challenged, e.g. deaf, hard of hearing, blind, vision impaired, mobility impaired, or other physical or mental challenges not listed?
- How many people living in your home are smokers?
- What is the race or ethnic group of the people in this household? (can check more than one: e.g., White and Hispanic)
- African American
- Hispanic/Latino
- Native American
- White
- Asian Pacific Islander
- Other__________
Time home safety visit ended: _______________________
Signed: _____________________________________________
Date: _______________________________________________
Program representative/witness: _____________________