Slide 1

Mississippi StateFire Marshals OfficeSmoke Alarm Installation TrainingTammy L. PeavyFire Safety Education Officer

AdvertisingNO give aways-alarms MUST be installedNewspaperRadioTVFlyersSign in sheetsApplicationsDoor-to-doorWord of mouthMake a dateResidents are homeAssistant/caregiver is present Translator is presentInteracting with Residents Address by formal name (Mr., Ms., Mrs., etc.)Identify yourself clearlyWear a name badgeOR wear organization clothingOR go in a marked vehicleBe persuasive, but respect persons right to say noSocial EtiquetteTips for installers who work with people with disabilities General TipsUse people first languageNever say handicapped or specialNever touch or distract a service animal without prior permissionAvoid making assumptionsDont be afraid to ask questions.Try to give people with disabilities optionsGeneral TipsDisregard the idea that you are saving people with disabilitiesA few simple guidelinesTreat adults as adultsDont be embarrassed if you use common expressionsMake eye contact with the person who is deaf rather than the translatorWho gets conventional smoke alarms?Owner-occupied homesNo rental propertyNo businessesNo churchesWho gets conventional smoke alarms?Owner-occupied homesLow income familiesOlder adultsFamilies with children under 14 years oldPeople with disabilitiesRecommendationsRemove smoke alarms that are 10 or more years oldRemove non-working smoke alarmsResidents have qualified electrician remove or replace existing hardwired smoke alarms-DO NOT remove themConventional Smoke AlarmsONLY use alarms provided by the State Fire Marshals Office. Do NOT supplement the program with other alarms.10-year lithium power packNo need to replace batteriesSealed alarmPower pack cannot be unplugged or removedPower pack will not fit other devicesConventional Smoke AlarmsAlarm activates when power cell insertedTest/silence buttonUsed to test alarmAllows resident to silence nuisance alarmsSilences alarm for 10 minutes unless smoke conditions persistTesting and MaintenanceShow residents how to test the smoke alarmsInstruct residents to test smoke alarms monthlyInstruct residents to clean smoke alarms monthly with vacuum cleaner soft brush attachment or dusterShow residents how to use the test/silence buttonLeave the instructions from the package with the residentsAfter 10 years or when the alarm starts to chirp, residents should replace the alarmConventional Smoke Alarm InstallationOutside each sleeping areaInside each sleeping roomOn each level of the home, including basementAreas separated by a door from the required locationsConventional Smoke Alarm Installation

Conventional Smoke Alarm Installation

Conventional Smoke Alarm Installation

Conventional Smoke Alarm Installation

Conventional Smoke Alarm InstallationOn ceilingAt least 4 from wall

-OR-

On wallAt least 4 from ceilingNot more than 12 from ceilingConventional Smoke Alarm Installation

ORConventional Smoke Alarm Installation

Conventional Smoke Alarm Installation

AVOID putting smoke alarms inKitchensGaragesBathroomsAreas where temperature or humidity are outside manufacturers limits-not below 40F or above 100F (includes most attics)AVOID putting smoke alarms Where mounting surface could become too hot or too coldWithin 3 of a bathroom or kitchen doorIt is best to install smoke alarms at least 10-12 from cooking appliances, where possibleWithin 3 of a supply air registerWithin 3 of air flow pathWithin 3 of ceiling fan blade tipsMobile Homes Many mobile homes built before 1978 have little or no insulation. In these homes or if you are unsure of the age, install smoke alarms on the interior walls only.

Who gets a SafeAwake alert device?People who are deafPeople who are hard of hearingOlder adultsMay be installed in rental propertySafeAwake alert deviceActivated by conventional smoke alarm T-3 alarm patternEmits a high-decibel, low frequency audible signalWhite flashing lightBed shakerBattery back-upUse only CR-123lithium batteriesPortable-take it withyou when you travel

SafeAwake alert deviceRed lightbed shaker unpluggedYellow lightbatteries lowGreen lightSolid-on AC powerFlashing-on battery powerSafeAwake TestingShow resident how to test the SafeAwake alarmInstruct resident to test alarm monthlyAlarm will alert 30 seconds when triangular button is pressedAlarm will alert 2 minutes when conventional smoke alarm is tested for full T-3 signalLeave the instructions from the package with the residentSafeAwake InstallationIn every room where a person who is deaf or hard of hearing sleepsAlso install a conventional smoke alarm in this roomWho gets a Gentex alarm?People who are deafMay be installed in rental property

Gentex AlarmPhoto-electricStrobe lightHigh frequency audible signalBattery back upDoes not operate strobe

Gentex Alarm TestingShow residents how to test the smoke alarmTurn knob to TEST 1, wait 20 seconds for sound and flashTurn knob to NORMAL, wait 20 seconds for sound and flashing to stopInstruct residents to test smoke alarm monthlyInstruct residents to clean smoke alarm monthly with vacuum cleaner soft brush attachment or dusterLeave the instructions from the package with the residentsGentex InstallationIn living room/common area near wall outlet that is not controlled by an on/off switchIn any room frequently occupied by a person who is deafOfficeDenProvide fire safety and escape planning informationReview all educational handouts with the residents

A fire safety DVD will be provided to people who are deaf or hard of hearing

Installer ResponsibilitiesInstall alarms according to the Mississippi Fire Marshals Office guidelinesComplete a survey/waiver form for each home visitedEvery week, mail or deliver all forms to your smoke alarm coordinatorDistributionEach organization must have a smoke alarm coordinatorMust return forms showing installation before more alarms distributedPick up alarms at distribution pointDelivery may be possibleTransfer form

TransferForm must be completed when receiving/distributing alarmsOrganization should track number of alarms distributed to each installerFormsOnly use forms provided by the State Fire Marshals Office-no copiesNO pencilsNO red inkWrite legiblyCheck spellingDo NOT abbreviate organization nameCorrectionsDraw a single line through the error, and write the correct information above, below, or to the sideIf you check the wrong box, circle the correct answerIncomplete forms will be returnedWaiver

Complete 1 perHOUSE

Name of organization

Name of community

Physical addressSame as on front of form

PRINT nameIf residents writing is illegible, print name for themHave resident sign formMUST be over 18Date of installation

If resident is unable to write, have them mark XWrite His/Her Mark beside XPrint nameHis mark-John Smith X

PRINT nameCANNOT be same as residentSignDate of installationSurvey*

Complete 1 perHOUSE

*Some forms vary

Date of installation

Person installing alarmsSame on all formsNOT organization

Do NOT leave blank

Include City, State, Zip CodeUse correct zip codeNO P. O. BoxesNO Route/Box addressesIf more than one house at same address, write Second House on form

If same as physical address, write Same as aboveInclude City, State, Zip CodeUse correct zip codeNO Route/Box addressesIf more than one house at same address, write Second House on form

Only used for evaluationNOT all residents will receive an email

Include area codeOnly used for evaluationNOT all residents will receive a call

County where home is located

Do not leave blanksUse 0 or N/A

Permanent residentsNOT people who frequently say overnight

Over age 65NOT the age

14 years or youngerNOT the age

Disabilities that would make escape difficult or impossibleDo NOT include deaf or hard of hearing

Number of people who are deaf

Number of people who are hard of hearing

Number of floors/ stories

Number of smoke alarms BEFORE you installedIf NO, skip questions 12-18

If there is only 1 level and 1 existing smoke alarm, this should be YESIf yes, skip #13

The lowest level of the home above ground is the first floor

A sleeping area is a room or group of rooms where people sleep

Include rooms that are not bed rooms

Does not include the alarms you install

You MUST test all existing alarmsIf you did not, explain why not

CANNOT be more than #11

Number of First Alert smoke alarms installed

Number of Kidde smoke alarms installed

Number of SafeAwake alarms installed

Number of Gentex alarms installed

This is required!If no, note why you did not

This is required!If no, note why you did not

Number of people talked to about handoutsQuestions?Sheet1

Waiver Form Mississippi Fire Marshals Office Smoke Alarm Installation Program-2010

At my request, established(organization name)

to install smoke alarms in residences in(community)has voluntarily installed one or more smoke alarms in my home located at

(address of smoke alarm installation)

In consideration for voluntarily providing and installing these smoke alarm(s) in my home, I, for myself, my heirs, executors, administrators, or successors, hereby waive any actions or claims of any nature that I have or might in the future have against any and all individual or organizational participants in the above referenced Program, including but not limited to the fire department, the municipality, and the Mississippi Fire Marshals Office and any of their officers, agents, or employees growing out of or resulting from the installation and/or failure of the smoke alarms, and I further agree to hold harmless any and all organizational and individual participants in the above referenced Program from and against all damages of any kind, to persons or property, growing out of or resulting from the installation and/or failure of such smoke alarms in my referenced home.

By signing this document, I certify that the smoke alarms were tested in my presence and are in good working order. Furthermore, I acknowledge that I have received information from the installer regarding proper smoke alarm maintenance and understand that the maintenance is my responsibility.

I acknowledge having read, understood, and agreed to the above waiver, release, and indemnity.

Print nameSignatureDate

Witness (print name)SignatureDate

NOTE: This form generally indicates that the occupant agrees to waive his or her rights to sue the individual, fire department, Mississippi Insurance Department, or any other organization or individual involved in the installation of the smoke alarms if a fire occurs after the alarm has been installed and tested. The purpose of the waiver is to protect the individual and organizations involved against liability arising from the installation or operation of the smoke alarm. This statement is intended for information only. The terms of the waiver themselves shall prevail if there are any questions. You should seek advice if you do not understand this waiver.

Sheet2

Sheet3

Sheet1

Waiver Form Mississippi Fire Marshals Office Smoke Alarm Installation Program-2010

At my request, established(organization name)

to install smoke alarms in residences in(community)has voluntarily installed one or more smoke alarms in my home located at

(address of smoke alarm installation)

In consideration for voluntarily providing and installing these smoke alarm(s) in my home, I, for myself, my heirs, executors, administrators, or successors, hereby waive any actions or claims of any nature that I have or might in the future have against any and all individual or organizational participants in the above referenced Program, including but not limited to the fire department, the municipality, and the Mississippi Fire Marshals Office and any of their officers, agents, or employees growing out of or resulting from the installation and/or failure of the smoke alarms, and I further agree to hold harmless any and all organizational and individual participants in the above referenced Program from and against all damages of any kind, to persons or property, growing out of or resulting from the installation and/or failure of such smoke alarms in my referenced home.

By signing this document, I certify that the smoke alarms were tested in my presence and are in good working order. Furthermore, I acknowledge that I have received information from the installer regarding proper smoke alarm maintenance and understand that the maintenance is my responsibility.

I acknowledge having read, understood, and agreed to the above waiver, release, and indemnity.

Print nameSignatureDate

Witness (print name)SignatureDate

NOTE: This form generally indicates that the occupant agrees to waive his or her rights to sue the individual, fire department, Mississippi Insurance Department, or any other organization or individual involved in the installation of the smoke alarms if a fire occurs after the alarm has been installed and tested. The purpose of the waiver is to protect the individual and organizations involved against liability arising from the installation or operation of the smoke alarm. This statement is intended for information only. The terms of the waiver themselves shall prevail if there are any questions. You should seek advice if you do not understand this waiver.

Sheet2

Sheet3

Sheet1

Waiver Form Mississippi Fire Marshals Office Smoke Alarm Installation Program-2010

At my request, established(organization name)

to install smoke alarms in residences in(community)has voluntarily installed one or more smoke alarms in my home located at

(address of smoke alarm installation)

In consideration for voluntarily providing and installing these smoke alarm(s) in my home, I, for myself, my heirs, executors, administrators, or successors, hereby waive any actions or claims of any nature that I have or might in the future have against any and all individual or organizational participants in the above referenced Program, including but not limited to the fire department, the municipality, and the Mississippi Fire Marshals Office and any of their officers, agents, or employees growing out of or resulting from the installation and/or failure of the smoke alarms, and I further agree to hold harmless any and all organizational and individual participants in the above referenced Program from and against all damages of any kind, to persons or property, growing out of or resulting from the installation and/or failure of such smoke alarms in my referenced home.

By signing this document, I certify that the smoke alarms were tested in my presence and are in good working order. Furthermore, I acknowledge that I have received information from the installer regarding proper smoke alarm maintenance and understand that the maintenance is my responsibility.

I acknowledge having read, understood, and agreed to the above waiver, release, and indemnity.

Print nameSignatureDate

Witness (print name)SignatureDate

NOTE: This form generally indicates that the occupant agrees to waive his or her rights to sue the individual, fire department, Mississippi Insurance Department, or any other organization or individual involved in the installation of the smoke alarms if a fire occurs after the alarm has been installed and tested. The purpose of the waiver is to protect the individual and organizations involved against liability arising from the installation or operation of the smoke alarm. This statement is intended for information only. The terms of the waiver themselves shall prevail if there are any questions. You should seek advice if you do not understand this waiver.

Sheet2

Sheet3

Sheet1

Waiver Form Mississippi Fire Marshals Office Smoke Alarm Installation Program-2010

At my request, established(organization name)

to install smoke alarms in residences in(community)has voluntarily installed one or more smoke alarms in my home located at

(address of smoke alarm installation)

In consideration for voluntarily providing and installing these smoke alarm(s) in my home, I, for myself, my heirs, executors, administrators, or successors, hereby waive any actions or claims of any nature that I have or might in the future have against any and all individual or organizational participants in the above referenced Program, including but not limited to the fire department, the municipality, and the Mississippi Fire Marshals Office and any of their officers, agents, or employees growing out of or resulting from the installation and/or failure of the smoke alarms, and I further agree to hold harmless any and all organizational and individual participants in the above referenced Program from and against all damages of any kind, to persons or property, growing out of or resulting from the installation and/or failure of such smoke alarms in my referenced home.

By signing this document, I certify that the smoke alarms were tested in my presence and are in good working order. Furthermore, I acknowledge that I have received information from the installer regarding proper smoke alarm maintenance and understand that the maintenance is my responsibility.

I acknowledge having read, understood, and agreed to the above waiver, release, and indemnity.

Print nameSignatureDate

Witness (print name)SignatureDate

NOTE: This form generally indicates that the occupant agrees to waive his or her rights to sue the individual, fire department, Mississippi Insurance Department, or any other organization or individual involved in the installation of the smoke alarms if a fire occurs after the alarm has been installed and tested. The purpose of the waiver is to protect the individual and organizations involved against liability arising from the installation or operation of the smoke alarm. This statement is intended for information only. The terms of the waiver themselves shall prevail if there are any questions. You should seek advice if you do not understand this waiver.

Sheet2

Sheet3

Sheet1

Waiver Form Mississippi Fire Marshals Office Smoke Alarm Installation Program-2010

At my request, established(organization name)

to install smoke alarms in residences in(community)has voluntarily installed one or more smoke alarms in my home located at

(address of smoke alarm installation)

In consideration for voluntarily providing and installing these smoke alarm(s) in my home, I, for myself, my heirs, executors, administrators, or successors, hereby waive any actions or claims of any nature that I have or might in the future have against any and all individual or organizational participants in the above referenced Program, including but not limited to the fire department, the municipality, and the Mississippi Fire Marshals Office and any of their officers, agents, or employees growing out of or resulting from the installation and/or failure of the smoke alarms, and I further agree to hold harmless any and all organizational and individual participants in the above referenced Program from and against all damages of any kind, to persons or property, growing out of or resulting from the installation and/or failure of such smoke alarms in my referenced home.

By signing this document, I certify that the smoke alarms were tested in my presence and are in good working order. Furthermore, I acknowledge that I have received information from the installer regarding proper smoke alarm maintenance and understand that the maintenance is my responsibility.

I acknowledge having read, understood, and agreed to the above waiver, release, and indemnity.

Print nameSignatureDate

Witness (print name)SignatureDate

NOTE: This form generally indicates that the occupant agrees to waive his or her rights to sue the individual, fire department, Mississippi Insurance Department, or any other organization or individual involved in the installation of the smoke alarms if a fire occurs after the alarm has been installed and tested. The purpose of the waiver is to protect the individual and organizations involved against liability arising from the installation or operation of the smoke alarm. This statement is intended for information only. The terms of the waiver themselves shall prevail if there are any questions. You should seek advice if you do not understand this waiver.

Sheet2

Sheet3

Sheet1

Waiver Form Mississippi Fire Marshals Office Smoke Alarm Installation Program-2010

At my request, established(organization name)

to install smoke alarms in residences in(community)has voluntarily installed one or more smoke alarms in my home located at

(address of smoke alarm installation)

In consideration for voluntarily providing and installing these smoke alarm(s) in my home, I, for myself, my heirs, executors, administrators, or successors, hereby waive any actions or claims of any nature that I have or might in the future have against any and all individual or organizational participants in the above referenced Program, including but not limited to the fire department, the municipality, and the Mississippi Fire Marshals Office and any of their officers, agents, or employees growing out of or resulting from the installation and/or failure of the smoke alarms, and I further agree to hold harmless any and all organizational and individual participants in the above referenced Program from and against all damages of any kind, to persons or property, growing out of or resulting from the installation and/or failure of such smoke alarms in my referenced home.

By signing this document, I certify that the smoke alarms were tested in my presence and are in good working order. Furthermore, I acknowledge that I have received information from the installer regarding proper smoke alarm maintenance and understand that the maintenance is my responsibility.

I acknowledge having read, understood, and agreed to the above waiver, release, and indemnity.

Print nameSignatureDate

Witness (print name)SignatureDate

NOTE: This form generally indicates that the occupant agrees to waive his or her rights to sue the individual, fire department, Mississippi Insurance Department, or any other organization or individual involved in the installation of the smoke alarms if a fire occurs after the alarm has been installed and tested. The purpose of the waiver is to protect the individual and organizations involved against liability arising from the installation or operation of the smoke alarm. This statement is intended for information only. The terms of the waiver themselves shall prevail if there are any questions. You should seek advice if you do not understand this waiver.

Sheet2

Sheet3

Sheet1

Waiver Form Mississippi Fire Marshals Office Smoke Alarm Installation Program-2010

At my request, established(organization name)

to install smoke alarms in residences in(community)has voluntarily installed one or more smoke alarms in my home located at

(address of smoke alarm installation)

In consideration for voluntarily providing and installing these smoke alarm(s) in my home, I, for myself, my heirs, executors, administrators, or successors, hereby waive any actions or claims of any nature that I have or might in the future have against any and all individual or organizational participants in the above referenced Program, including but not limited to the fire department, the municipality, and the Mississippi Fire Marshals Office and any of their officers, agents, or employees growing out of or resulting from the installation and/or failure of the smoke alarms, and I further agree to hold harmless any and all organizational and individual participants in the above referenced Program from and against all damages of any kind, to persons or property, growing out of or resulting from the installation and/or failure of such smoke alarms in my referenced home.

By signing this document, I certify that the smoke alarms were tested in my presence and are in good working order. Furthermore, I acknowledge that I have received information from the installer regarding proper smoke alarm maintenance and understand that the maintenance is my responsibility.

I acknowledge having read, understood, and agreed to the above waiver, release, and indemnity.

Print nameSignatureDate

Witness (print name)SignatureDate

NOTE: This form generally indicates that the occupant agrees to waive his or her rights to sue the individual, fire department, Mississippi Insurance Department, or any other organization or individual involved in the installation of the smoke alarms if a fire occurs after the alarm has been installed and tested. The purpose of the waiver is to protect the individual and organizations involved against liability arising from the installation or operation of the smoke alarm. This statement is intended for information only. The terms of the waiver themselves shall prevail if there are any questions. You should seek advice if you do not understand this waiver.

Sheet2

Sheet3

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:______

Sheet2

Sheet3

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:______

Sheet2

Sheet3

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:______

Sheet2

Sheet3

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:______

Sheet2

Sheet3

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:______

Sheet2

Sheet3

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:______

Sheet2

Sheet3

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:______

Sheet2

Sheet3

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:______

Sheet2

Sheet3

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:______

Sheet2

Sheet3

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:______

Sheet2

Sheet3

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:______

Sheet2

Sheet3

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:______

Sheet2

Sheet3

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:______

Sheet2

Sheet3

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:______

Sheet2

Sheet3

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:______

Sheet2

Sheet3

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:______

Sheet2

Sheet3

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:______

Sheet2

Sheet3

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:______

Sheet2

Sheet3

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:______

Sheet2

Sheet3

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:______

Sheet2

Sheet3

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:______

Sheet2

Sheet3

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:______

Sheet2

Sheet3

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:______

Sheet2

Sheet3

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:______

Sheet2

Sheet3

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:______

Sheet2

Sheet3

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:______

Sheet2

Sheet3

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:______

Sheet2

Sheet3

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:______

Sheet2

Sheet3

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:______

Sheet2

Sheet3

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?