Reading This May Save Your Life

This questionnaire will assist external and internal partners to prioritise properties and personal Home Fire Safety Checks or the delivery of information packs if a HFSC is not required, but the occupier requires information on home safety.

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1. Occupier Details

Date:
Title:	Choose Title Mr Ms Mrs Miss
First Name:
Last Name:
House No:
House Name:
Road :
Area:
Borough:	Choose District Knowsley Liverpool Sefton St Helens Wirral
Postcode:
Telephone:
Alt Number:
Email:
2. Home Status
Is your home:	Privately Owned? Rented?
3. Six Point Questionnaire
3.1 Does your home have a working smoke alarm?:	Yes No
3.2: Is anyone in the household over the age of 60?	Yes No
3.3: Does anyone in the household smoke?	Yes No
3.4: Does anyone have mobility problems?	Yes No
3.5: Does anyone in the home have mental health issues?	Yes No
3.6: Do you need a fire escape plan creating for you?	Yes No
MF&RS (Merseyside Fire & Rescue Service) will process the information you supply for the purposes of reducing the risk of fire and possible injury. MF&RS will record this information in paper form and our electronic database system for HFSC's. The information will be stored securely for five years, in line with current retention schedules. Please select box below if you agree with this.
MF&RS will share this information securely with other agencies for the reason above. Please tick the box below if you wish to decline this.You are entitled to see your personal data held by MF&RS. If you wish to see your personal data please contact Corporate Information Sharing Officer: Tel No 0151 296 4416. Decline to share this information