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OPTIMUM FIRE SAFETY SURVEY
QUICK 90 SECOND SURVEY
1.
Check any of the dangers you are concerned about.
Home Fire
Carbon Monoxide
Flooding or Water damage
Frozen Pipes
2.
Have you experienced any of the dangers above? If yes, please specify.
Home Fire
Carbon Monoxide Poisoning
Flooding or Water Damage
Frozen Pipes
Other (please specify)
3.
Do you have children? Pets? or Both?
Children
Pets
Both
Neither
4.
Married? Living Together? Single?
Married
Living Together
Single
5.
Your Occupation
6.
Spouse Occupation
7.
Age Range
Under 18
18-24
25-34
35-44
45-54
55-64
65+
8.
Do you own or rent
Own
Rent
9.
If selected, you may be contacted at # listed
Name
Address
City / Town
State / Province
Zip/Postal Code
Cellphone
10.
Who sent you this or whose social media post did you click on?
Current Progress,
0 of 10 answered
