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2. Service Acknowledgement Form
4. Home Address
6. City
7. State
8. Zip Code
10. # of new 10-year smoke alarms installed and tested?
11. Did the resident(s) create a fire escape plan?

    1. yes
    2. no
13. # of new 9-volt smoke alarms installed and tested?
14. Did the resident(s) review the Home Fire Safety Checklist?

    1. yes
    2. no
16. # of new bedside alarms installed and tested for people who are deaf or hard of hearing?
17. Did the resident(s) learn about a local hazard?*

    1. yes
    2. no
19. # of Batteries replaced?
20. If above answer was yes, what hazard?
22. Resident Certification
    I am a resident of the home located at the address found above. I acknowledge that today I received the services indicated in the Services Provided section. I have also received instruction in the proper used and maintenance of smoke alarms.I understand that smoke alarms make a sound to warn persons in my home in the event of a fire, but that smoke alarms work only if they have been properly maintained. It is my responsibility to maintain the smoke alarms in my home per the manufacturer's recommendations and to test my smoke alarms monthly. It is also my responsibility to make sure that I have the appropriate number of smoke alarms in my home and that the smoke alarm is are in appropriate locations. The American Red Cross and its partners are not responsible for determining teh appropriate number or placement of smoke alarms. Your signature indicates that you have read the information above and that you agree with its content.
24. Resident's Printed Name*
25. Red Cross / Partner Printed Name
27. Resident's Signature
28. Red Cross / Partner Signature
30. Date and Time*
    Date and Time

    Date and Time
31. Date
    Date

    Date
33. Initial Assessment Upon Visit*
    How many people live here?
34. How many pre-existing smoke alarms does the household already have?
36. How many youth ages 17 and under live here?
37. How many pre-existing smoke alarms are working?
39. How many adults ages 65 or older live here?
40. Is a bedside alarm needed for people who are deaf or hearing impaired?*

    1. yes
    2. no
42. How many individuals with a disability, or an access or functional need live here?
43. Additional Notes:
45. Optional Reporting Fields
47. Optional 1.
    National Coalition Organization(s)
48. Optional 2.
    Local Coalition Organization(s)
50. Information for Future Follow-up
52. Did the client provide contact information?

    1. yes
    2. no
54. Cell Phone Number
55. Fax Number
57. Email Address
59. Electronic Signature Agreement

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
61. Electronic Signature
65. Administrative Section
67. Has this record been entered into the online portal?

    1. yes
    2. not yet
68. If data has been entered into the online portal, what date was it submitted?
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70. Submit Submit and Print

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