Sheet1Mississippi State Fire Marshal's Office2010Smoke Alarm Installation ProgramSurvey/Waiver Form1. Date:12. Was there at least one smoke alarm on every level of the home?

yes no2. Installer's Name:13. If "no", which level(s) did not have a smoke alarm? basement first floor second floor otherspecify:________________3. Head of Household:14. Was there a smoke alarm outside each sleeping area? yes no15. Was there a smoke alarm inside each sleeping room?4. Physical Address: yes no16. How many smoke alarms were more than 10 years old? zero one two three or moreif more than 3, how many? _______5. Mailing Address:17. How many of the old smoke alarms did you test? zero one two three or moreif more than 3, how many? _______If not tested, why not?6. Email Address:

7. Phone #:18. How many of the old alarms did not work? zero one two three or more8. Countyif more than 3, how many? _______19. How many First Alert smoke alarms did you install?9. Total number of people living in the home: ____ zero one two three or moreNumber of older adults living in the home:_______if more than 3, how many? _______Total number of children under age 14 living in the home: _____20. How many Kidde smoke alarms did you install? zero one two three or moreTotal number of people living in the home with a disability: _____if more than 3, how many? _______21. How many SafeAwake alarms did you install?Total number of people that are deaf living in the home: _____ zero one two three or moreif more than 3, how many? _______Total number of people that are hard of hearing living in the home: _____22. How many Gentex alarms did you install? zero one two three or more10. Number of levels in the homeif more than 3, how many? _______ one two three or more23. Did you discuss home escape planning with the residents?if more than 3, how many? _______11. Were there any smoke alarms in the home before you installed new alarms? yes no24. Did you discuss the handouts with the residents? yes no yes noIf yes, how many? _____If no, skip questions 12-18.25. Total number of people talked to:______

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