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Thermal Fuse Installation Form
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* Indicates required question
Q
Date of Installation.
MM
/
DD
/
YYYY
Agency.
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Your answer
Name of installer.
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Your answer
Address of install.
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Your answer
City, county, state
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Your answer
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Albany
Big Horn
Campbell
Carbon
Converse
Crook
Fremont
Goshen
Hot Springs
Johnson
Laramie
Lincoln
Natrona
Niobrara
Park
Platte
Sheridan
Sublette
Sweetwater
Teton
Uinta
Washakie
Weston
Number of units installed.
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1
2
3
4
5
Age of patient.
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Gender of Patient:
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Female
Male
Prefer not to say
Smoke Alarm Present:
Yes
No
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Smoke Alarm Working:
Yes
No
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Smoke alarm less than 10 years old:
Yes
No
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