Omaha Fire Department
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Smoke detectors for the deaf and hard of hearing
- Needs Survey -

**  Available to residents of Omaha, Nebraska.  **
    (Including Millard and Elkhorn)

First Name *
Last Name *
Address *
City *
State *
Zip Code *
Home Phone Number (Including Area Code) *
Mobile Phone Number (Including Area Code) *
Email Address *
Preferred Contact Method *
Home Phone (Voice or VideoPhone) - Mobile (Voice)
How many Floors/ Levels does the house have? *
How many total people live in the household? *
How many people living in the household are Deaf or Hard of Hearing? *
The Family Members that could benefit from this Program, Do they consider themselves Deaf or Hard of Hearing? *
How many separate sleeping areas or bedrooms in the home are utilized by individuals that could benefit from this device? *
If an interpreter is available, would you like one to be present at the installation.  (An interpreter may not be available.) *
During your waking hours, do you wear amplification or a Cochlear Implant? *
If you do wear amplification or a Cochlear Implant, is it adequate to alert you to the sound of a normal Smoke Alarm? *
Additional Information
*fields required to submit this form.  

Please understand that we are gathering information from our community and are seeking grant funding to support this project.  There will be a delay between the submission of your application and the actual installation of the detector.  Receipt of the grant is not guaranteed.
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