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State * Zip * Date: * Date: * Initial Assessment Upon Visit Additional Notes: Optional Reporting Fields National Coalition Org(s) Information for Future Follow-up Administrative Section Your signature indicates that you have read the information above and that you agree with its content. Optional 1. If data has been entered into the online portal, what date was it submitted? Other Phone Number How many adults ages 65 and older live here? Is a bedside alarm needed for people who are deaf or hard of hearing? * Yes / No Local Coalition Org(s) Has this record been entered into the online portal? Yes Ƒ Cell Phone Number Did the client provide contact info? * Yes / No Email Address Resident's Printed Name * Optional 2. How many pre-existing smoke alarms are working? How many youth ages 17 and under live here? Service Acknowledgment Form 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 use and maintenance of smoke alarms. I understand that smoke alarm(s) 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 alarm(s) in my home per the manufacturer’s recommendations and to test my smoke alarms It is also my responsibility to make sure that I have the appropriate number of smoke alarms in my home and that the smoke alarms are in appropriate locations. The American Red Cross and its partners are not responsible for determining the appropriate number or placement of smoke alarms. How many pre-existing smoke alarms does the household already have? Home Address Services Provided # of new 9-volt smoke alarms installed and tested? * City * Address * Apt / Unit # * (Mark "NA" if Not Applicable) If yes, what hazard? Did the resident(s) review the Home Fire Safety Checklist? * Yes / No # of batteries replaced? * # of new bedside alarms installed and tested for people who are deaf or hard of hearing? * Did the resident(s) learn about a local hazard? * Yes / No How many individuals with a disability, or an access or functional need live here? Red Cross/ Partner Signature * Resident's Signature * # of new 10-year smoke alarms installed and tested? * Did the resident(s) create a fire escape plan? * Yes / No Red Cross/ Partner Printed Name * How many people live here? * SIGN SIGN