Fire Risk Assessment

Please select one answer for each question that best describes the situation in your home.

1. Does your home have one or more smoke alarms (also called smoke detectors)?

   	Yes.
   	No.
   	Don't know.

2. Is there a smoke alarm located near the sleeping area(s) of your home (i.e., typically in the hallway outside bedrooms)?

   	Yes, there is a smoke alarm located near sleeping area(s).
   	Yes, there is a smoke alarm located near sleeping area(s) PLUS one inside every bedroom.
   	No, there is no smoke alarm located near sleeping area(s).
   	There are no smoke alarms anywhere in the house.

3. When did you last test the smoke alarms AND restore them all to working order if needed?

   	Within the past month.
   	Two to three months ago.
   	More than three months ago.
   	There are no smoke alarms anywhere in the house.

4. Would anyone in the house have difficulty hearing or responding quickly to the sound of a smoke alarm (e.g., a particularly heavy sleeper, someone who is hard of hearing, or someone who regularly uses alcohol or medication that causes drowsiness)?

   	Yes.
   	No.

5. In the event of fire, would anyone need help to get out of the house?

   	Yes. One or more people in my household could not get out easily without physical assistance.
   	Very likely. Some people in my household might need guidance or assistance.
   	Maybe. Some people in my household (or some who visit me occasionally) might need assistance.
   	No, everyone would be able to get out of the house without help.

6. If anyone would need help to get out of the house, who would provide the help?

   	Someone from outside (fire department or neighbors).
   	Someone else who lives in the house.
   	Don’t know - - haven’t planned for it.
   	No one would need assistance.

7. If a fire started when people were asleep, would anyone have to go up or down stairs, or out a second floor (or higher) window in order to escape the fire?

   	Yes, everyone.
   	Yes, some people.
   	No

8. Do you have a plan for escaping from the house in the event of fire?

   	Yes, a specific plan.
   	Yes, but only a general idea.
   	No.

9. Have the details of the escape plan been discussed with every person in the house (e.g., how to find and follow escape routes, where to meet once outside)?

   	Yes.
   	No.
   	Don’t know.
   	We don’t have an escape plan.

10. Have you practiced the escape plan within the past six months?

    	Yes.
    	No.
    	We don’t have an escape plan.

11. Does anyone smoke in your home?

    	Yes, one or more regular smokers.
    	Yes, one or more occasional smokers, or visitors who smoke.
    	No.

12. How old is the youngest person who lives in the house?

    	6 or older.
    	Younger than 6.

13. How old is the oldest person who lives in the house?

    	85 or older.
    	75 to 84.
    	74 or younger.