Smoke Alarm Data Sheet

Department Name:
Address of this home safety check:
Pre-existing Conditions Outdoors
- Correct address is displayed and visible from the street.
- Weeds, grass, vines, or other growth that may be ignited is cut down and removed.
- Pools, hot tubs, or other large bodies of water are surrounded by four-foot fence or fence that meets local requirements with self-closing gates which lock on the "inside
- does not have a pool, hot tub, or other large body of water
Decks:
- have proper railings
- include handrails if more than three steps
- are securely fastened to the structure and supported (if it is an elevated deck)
- are free of rotten or decayed boards
- this house does not have a deck
Barbeque grills are located a sufficient distance away from:
- siding
- eaves
- tree branches
- combustible decks
- does not have a barbeque grill
Pre-existing Conditions Indoors
- Fire extinguishers are available on every level of the home.
- The home has an emergency supply kit.
- Emergency phone numbers are programmed in the phone or posted near it.
- Deadbolt locks can be unlocked from the inside without a key.
- Combustible storage is separate from heaters and heating devices.
- No storage on stairs or in a manner that blocks exit doors or rescue windows.
- Flammable liquids stored in proper containers & located far from heat/ignition sources.
- Laundry rooms/dryer vents free from lint accumulations (check under & behind dryers).
- Extension cords are not overloaded, worn, frayed, spliced or otherwise damaged.
- Extension cords are not run under carpets, through walls or ceilings.
- All electrical switches and receptacles have a proper cover plate.
- Child locks are installed on all cabinets used to store dangerous items, such as poisons, cleaners, matches, and lighters. (If applicable)
- The family has a home escape plan.
Carbon monoxide detectors are located:
- near each bedroom.
- on every level of the home.
- no carbon monoxide detectors in the home
Smoke alarms are:
- in every bedroom.
- on every level of the home, including the basement.
- outside of sleeping areas.
How many smoke alarms total were previously installed in the home?
How many smoke alarms were not operating, for any reason?
How many smoke alarms were over 10 years old?
Steps taken to increase safety
- Installed smoke alarms
How many smoke alarms were installed?
- Assisted family in developing a home escape plan.
- Posted correct house numbers in a location visible from the street.
Other, please list:
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Pre-existing Conditions Outdoors

Pre-existing Conditions Indoors

Steps taken to increase safety

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