Information
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Audit Title
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Conducted on
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Prepared by
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With your consent, Fire Attack Training L.L.C. has completed a fire safety survey of your home. The items checked “No” may put you and your family at risk. You are urged to correct these at once for your own safety. This survey does not identify future conditions such as failure of components, wiring or human behavior which could result in a fire.
Exterior Conditions
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House exterior is free from hazardous fire conditions
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Gas meter has a protective barrier or does not require one
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Exterior is void of excessive rubbish and vegetation that may pose a fire hazard
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House number is visible from the street
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Swimming pool and/or hot tub enclosed by locked fence.
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Propane grill is only used outdoors.
Smoke Alarms
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Smoke alarms located inside each bedroom.
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Smoke alarms located outside each bedroom.
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Smoke alarms located on each level of the home
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All smoke alarms located >10 feet from stove
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All smoke alarm batteries replaced every six months
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All smoke alarms work when tested.
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All smoke alarms < 10 years old.
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All smoke alarms tested monthly.
Carbon Monoxide Alarms
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Carbon monoxide alarm is located on each level of the home
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Carbon monoxide alarm batteries replaced at least annually
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Carbon monoxide alarm(s) < 7 years old
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Carbon monoxide alarms work when tested.
Fire Extinguishers
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A minimum 2A:10B:C fire extinguisher located on each level of the home
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Travel distance to an extinguisher is not > 40 feet
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All adults are trained to operate a fire extinguisher
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Each fire extinguisher inspected monthly
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Each fire extinguisher mounted in correct place with instructions facing outward
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Access to each fire extinguisher is unobstructed.
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Fire extinguisher instruction are legible.
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Fire extinguishers seal and tamper indicators intact.
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Fire extinguisher pressure gauge in operable range.
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Fire extinguisher has no evidence of corrosion or physical damage.
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Fire extinguisher does not need service or replacement.
Emergency Escape
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The occupants have a fire escape plan.
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Occupants have a designated outside meeting place.
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All occupants know the outside meeting place.
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All occupants know the primary and secondary escape routes from the bedrooms.
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The occupants practice the fire escape plan at least once every 3 months.
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Bedroom windows used as a secondary escape route open easily.
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Security bars on windows used as a secondary escape route have a quick release device and it is operational.
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Exit routes are free from obstructions.
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Doors do not have double-keyed locks.
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Emergency escape ladders provided for bedrooms on upper floors.
Electrical
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Electrical panel is accessible and in good condition.
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Circuit breakers are labeled.
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Outlets and switches have faceplates.
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Power strips are used with integral over current protection.
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Electrical cords do not run under carpet or rugs.
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Electrical cords are not a tripping hazard.
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Electrical cords are not used as fixed wiring.
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Kitchen and bathroom outlets are GFCI.
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Exterior, basement and garage outlets are GFCI.
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Sufficient airspace left around stereos and TVs.
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Small appliances unplugged when not in use.
Interior Conditions
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The home interior is devoid of excessive combustibles.
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Smoking is not allowed in the home.
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Emergency phone numbers are posted in the home.
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There is a solid core door between the garage and the homes interior.
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If smoking is allowed in the home, large ashtrays are provided and emptied each night.
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Matches & lighters are secured from children.
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Lit candles are not left unattended.
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Flammable liquids are properly stored.
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A minimum of one functioning flashlight is in the home.
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Clothes dryer vent duct is made of metal and is cleaned on a regular basis.
Heating & Cooking Conditions
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Fireplace ashes are properly disposed of outside the home.
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Fireplace has a proper screen and hearth.
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A clear 3' space is provided around the fireplace and all space heaters.
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Liquefied Petroleum (LP) gas heaters with self-contained fuel supplies are not used to heat the interior of the home.
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The chimney is inspected and cleaned annually.
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The furnace is inspected and cleaned annually.
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Hot water discharged in the home is < 120 degrees Fahrenheit.
Cooking Conditions
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Combustibles removed from the stovetop when not in use.
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Flammable objects, including pot holders, dish towels and curtains are at least 3' away from the stove.
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An adult stays in the kitchen when stove is in use.
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Pot & pan handles are turned in while cooking.
Equipment Installed
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Hardwired Smoke Alarm
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Battery Smoke Alarm
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Fire Extinguisher
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Carbon Monoxide Alarm
WAIVER, RELEASE AND HOLD HARMLESS AGREEMENT
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In consideration of the voluntary performance of a home fire safety survey of my home, I, on behalf of myself, and all members of family, as well as my heirs, executors, administrators or successors, hereby waive any claim or cause of action of any nature that I have, or in the future may have, against any and all individual or organizational participants in the home fire safety survey, including but not limited to Fire Attack Training L.L.C. and its officers, agents or employees, which claim or cause of action grows out of or results from a fire or other damage, following the said home fire safety survey; and I further hereby agree to release and hold harmless any and all organizational and individual participants including the aforesaid Fire Attack Training L.L.C. in the home fire safety survey from and against all damages of any kind, to persons or property, growing out of or resulting from a fire in my referenced home. I acknowledge having read, understood, and agreed to the above waiver, and release.
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Alegria Family Services employee
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Fire Attack Training LLC
