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”

  1. Type of home

    Detached house; Mobile home; Duplex/townhouse; Multifamily; Other

  2. 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

  3. Names of fire department representatives making the visit:
  4. 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

  1. Number of working smoke alarms (excluding private fire alarm system)
  2. Number of non-working smoke alarms (excluding private fire alarm system)
  3. Was a private fire alarm system present? (Do not test)
    If yes:

    1. Number of smoke alarms in the private fire alarm system
    2. Did the private fire alarm system appear to be working?

Installations Made

  1. 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) _____________
  2. Total number of alarms installed
    1. If zero alarms were installed, why?
  3. Number of working smoke alarms replaced due to age
  4. Number of non-working smoke alarms whose batteries were replaced (if any)
  5. Number of working smoke alarms whose batteries were replaced (if any)
  6. Total number of working smoke alarms at the end of the visit
  7. Did the home end up with the number of working smoke alarms required by code?
    If no:

    1. Why not?
      • Not enough time during visit
      • Not enough smoke alarms
      • Occupant refused (Why? Fill in.) ________________________________
    2. Was the occupant advised of the number of smoke alarms required to meet code?

Education Provided

  1. 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___________________
  2. Ask occupant: Do you have a fire escape plan?
    If yes:

    1. Was the fire escape plan practiced in the last year?
    2. Where is your meeting place? ( Credible site / Not credible site)
  3. 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)

  1. Do you own or rent your home?
  2. How many people live in your home?
  3. How many children living in your home are under age 5?
  4. How many people living in your home are over age 65?
  5. 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?
  6. How many people living in your home are smokers?
  7. 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: _____________________