Self-Inspection of Homes

Please answer all the following questions

(If you answer no to any of the following questions, or if you need assistance, please contact your local fire department.)

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* 1. Please provide the following information about your residence.

Name *

Address *

Address 2/Apartment # (optional)

Municipality *

Phone Number *

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* 2. Do you have a smoke alarm on each floor of your residence?

Yes

No

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* 3. Have you tested your smoke alarms this month?

Yes

No

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* 4. Have you changed the battery in your smoke alarms this year?

Yes

No

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* 5. Have you replaced your smoke alarms in the past 10 years?

Yes

No

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* 6. What is the expiration date of your smoke alarms?

Date / Time

Date

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* 7. Are your smoke alarms installed according to the installation instructions on the provided self-inspection document?

Yes

No

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* 8. If you heat with wood, oil or propane or have an attached garage, is your residence equipped with a carbon monoxide alarm?

Yes

No

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* 9. Do you have a portable fire extinguisher at home?

Yes

No

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* 10. Are there people with disabilities in your residence?

Yes

No