Address:

 

Email:

(optional)

 

1- Type of Dwelling ?

     House Duplex Tri-plex Townhouse Mobile Home Low-rise Apartment Cottage Other

 

2 - Number of Floors ?

     1 2 3 4 or More

 

3 - How many occupants live in the residents ?

     1 2 3 4 5 6 7 8 9 10 or more

 

4 - How many smoke detectors are there in the home ?

     0 1 2 3 4 5 6 7 8 9 10 or more

 

5 - Is there at least one on every level of the home ?

Yes

No

 

6 - If no, which levels do not have an alarm ?

Basement

1st Floor

2nd Floor

3rd Floor

other

 

7 - How many smoke alarms did you test ?

     0 1 2 3 4 5 6 7 8 9 10 or more

 

8 - How many smoke alarms did not work ?

     0 1 2 3 4 5 6 7 8 9 10 or more

 

9 - If the smoke alarm did not work, indicate the number of alarms with the following probem(s)

Battery Disconneted	0 1 2 3 4 5 6 7 8 9 10	Battery dead	0 1 2 3 4 5 6 7 8 9 10
Battery Missing	0 1 2 3 4 5 6 7 8 9 10	Hardwire Disconnected	0 1 2 3 4 5 6 7 8 9 10
Hardwire Power Off	0 1 2 3 4 5 6 7 8 9 10	Other	0 1 2 3 4 5 6 7 8 9 10

 

10 - How many batteries where replaced ?

       0 1 2 3 4 or More