DATE:  
REPORTING ORGANIZATION:
INSTALLER'S FIRST NAME:
INSTALLER'S LAST NAME:
OCCUPANT'S FIRST NAME:
OCCUPANT'S LAST NAME:
ADDRESS:
CITY: STATE:          ZIP:  
GPS Location (DEGREES MINUTES.SECONDS) LOOK UP WITH ADDRESS
LATITUDE: (Example: N35° 22.0416')
LONGITUDE: (Example: W078° 11.7455')
 
1. TYPE OF RESIDENCE:
 One Family  2-Family (Duplex)  Apartment  Manufactured Home (Mobile Home)
2. NUMBER OF LEVELS IN THE HOME:  
3. HOW MANY SMOKE ALARMS WERE IN THE HOME BEFORE YOU INSTALLED NEW ALARMS? (If zero, please skip to Question 12)   
4. WAS THERE AT LEAST ONE SMOKE ALARM ON EVERY LEVEL OF THE HOME? (If YES, please skip to Question 6)  Yes  No
5. WHICH LEVEL(S) DID NOT HAVE A SMOKE ALARM?
BASEMENT:  Smoke Alarm Present  No Smoke Alarm Present  N/A
FIRST FLOOR:  Smoke Alarm Present  No Smoke Alarm Present  N/A
SECOND FLOOR:  Smoke Alarm Present  No Smoke Alarm Present  N/A
OTHER FLOOR(S):  Smoke Alarm Present  No Smoke Alarm Present  N/A
OTHER (SPECIFY):
6. WAS THERE A SMOKE ALARM OUTSIDE EACH SLEEPING AREA?    Yes  No
7. HOW MANY SMOKE ALARMS DID YOU TEST?  
8. HOW MANY SMOKE ALARMS DID NOT WORK?  
9. IF ALARMS DID NOT WORK, HOW MANY ALARMS HAD THE FOLLOWING PROBLEMS?
BATTERY DISCONNECTED:  
BATTERY DEAD:  
BATTERY MISSING:  
OTHER:  
OTHER (SPECIFY):  
10. HOW MANY SMOKE ALARMS WERE MORE THAN 10 YEARS OLD?  
11. HOW MANY BATTERIES DID YOU REPLACE?  
12. HOW MANY NEW SMOKE ALARMS DID YOU INSTALL?  
HOW MANY IONIZATION:  
HOW MANY PHOTOELECTRIC:  
13. WHAT SAFETY INFORMATION DID YOU LEAVE WITH THE HOME'S OCCUPANT? (Please check all that apply)  
NFPA COOKING SAFETY TIPS  
NFPA ELECTRICAL SAFETY TIPS  
NFPA SMOKE ALARM SAFETY AT HOME  
NFPA SMOKE ALARMS FOR PEOPLE DEAF OR HARD OF HEARING  
OTHER (SPECIFY):  
14. DID YOU HELP OCCUPANT FIND TWO WAYS OUT OF EVERY ROOM?  Yes  No
15. DID YOU HELP OCCUPANT SELECT AN OUTSIDE MEETING PLACE?  Yes  No
16. DID YOU HAVE OCCUPANT SIGN A WAIVER?  Yes  No
17. HOW MANY NEW CARBON MONOXIDE ALARMS DID YOU INSTALL?