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Facility Name |
Facility Address |
Telephone No. |
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YES |
NO |
N/A |
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1.
There are at
least two unblocked exits to the outside from the home (can include windows)....................................................................................................................... |
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2.
Electrical
wiring system appears in good repair............................................................. |
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3.
Electrical
outlets in rooms used by children have child-proof covers or are safety
outlets............................................................................................................................ |
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4.
Fuses or
circuit breakers in fuse box appear in good operating condition...................... |
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5.
Cords for
electrical appliances and lighting fixtures appear in good operating
condition....................................................................................................................... |
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6.
Extension
cords are used properly. (Not run
under rugs, not hooked over nails, not overloaded.) (Check
N/A if extension cords are not in use.)................................................................ |
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7.
Space
heaters are enclosed to prevent children from burning themselves....................... |
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8.
Space
heaters are vented to the outside.
(Check N/A if space heaters are not designed to vent to the outside).................................................................................................... |
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9.
Gas
appliances (heaters, water heaters, stoves) have metal tubing and metal
connections................................................................................................................... |
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10.
Central
heating system is periodically inspected by a qualified inspector....................... |
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11.
Wood burning
or gas log fireplaces are protected with a spark screen or guard............. |
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12.
Combustibles
are stored or placed well away from any stove, heater, or fireplace in the
home.............................................................................................................................. |
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13.
All lighters
and matches are kept out of reach of children............................................... |
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14.
Flammable
liquids are stored in safety cans and kept away from heat and children......... |
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15.
Paint is
kept in tightly closed metal containers............................................................... |
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16.
The premises
are free of rubbish, especially the attic, garage, and basement.................. |
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17.
Trash is
burned in an area away from the children.......................................................... |
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18.
There is an
operable #5 pound dry chemical fire extinguisher available for use in the
kitchen........................................................................................................................... |
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19.
Fire
extinguisher is serviced after each use and checked for proper weight at
least once a year............................................................................................................................. |
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20.
Family has
an evacuation plan for emergencies.............................................................. |
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21.
Fire drills
are practiced regularly................................................................................... |
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22.
There is a
method available to alert family to a fire (alarm, bell, etc.)............................... |
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Signature |
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Title |
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Date |