* 1. Fire department:

* 2. Fire Chief:

* 3. Address or P.O. Box:

* 4. City:

* 5. State:

* 6. ZIP:

* 7. Email address:

* 8. Fire deaths in 2016:

* 9. Fire deaths in 2017:

* 10. What are your department's active fire prevention programs? (Check all that apply)

* 11. Has your department had zero fire deaths or at least a 10 percent reduction in fire deaths from the previous year? (Please choose one or both.)

* 12. Do you have an active fire prevention program in place within your department? Briefly describe your program.

* 13. Briefly describe the resources (financial or in-kind) your department committed to fire prevention activities in 2017.

* 14. Please explain briefly how your fire prevention efforts increased in 2017 over 2016 and how those efforts have made a positive difference in your community.

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