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