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2. Home Smoke Alarm and Fire Safety Survey
4. 1. Do you have working smoke alarms installed in your home?

   1. Yes
   2. No
6. 2. Do you know the proper places to install smoke alarms within your residence?

   1. Yes
   2. No
8. 3. Smoke alarms should be installed on every level of the home, inside each bedroom and outside every sleeping area. Is this the case in your home?

   1. Yes
   2. No
10. 4. Where are the smoke alarms located in your home? Select all that apply.

    1. Kitchen
    2. Living Room
    3. Bedrooms
    4. Hallways
    5. Basement
    6. Garage
    7. Other
12. 5. How often do you test your smoke alarms?

    1. Monthly
    2. Every few months
    3. Once a year
    4. Never
14. 6. Have you ever disconnected a smoke alarm?

    1. Yes
    2. No
16. 7. Do you have a home fire escape plan?

    1. Yes
    2. No
18. 8. Would you like a home fire safety inspection?

    1. Yes
    2. No
20. 9. Please provide your name, phone number and address if you would like a fire safety inspection or are in need of smoke alarms. This information will not be made public or shared.
22. Name
23. Email Address
25. Address
27. City
28. State
29. Zip Code
31. Phone Number
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33. 1. Receive an email copy of this form.
34. Email address

    This field is not part of the form submission.

35. Submit

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