JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
Home Fire Pre-Plan
Complete this form so the Morocco Vol. Fire Department has a pre-plan of your home on file in the event of an emergency.
* Indicates required question
Family Name
*
Your answer
Street Address
*
Your answer
City
*
Morocco
Mount Ayr
Enos
Fair Oaks
Other:
Do you live inside town limits
Yes
No
Clear selection
How many people live in your house?
*
0
1
2
3
4
5
6
7
8
9
10
How many children (less than 10 years old) live in your home?
*
0
1
2
3
4
5
6
7
8
9
10
How many children (11-17 years old) live in your home?
*
0
1
2
3
4
5
6
7
8
9
10
How many adults (18-79 years old) live in your home?
*
0
1
2
3
4
5
6
7
8
9
10
How many adults (80 years old and older) live in your home?
*
0
1
2
3
4
5
6
7
8
9
10
Check any of the following about the people who live in your home: (Check all that apply)
*
Someone in my household requires assistance walking.
Someone in my household is bed bound, bed ridden or wheelchair bound.
Someone in my household suffers medical conditions that would hamper their ability to exit our home on their own in the event of a fire or other emergency.
Someone in my household requires the continuous use of medical oxygen.
There are infants or other small children in my home that would be unable to exit on their own.
Someone in my household is hearing impaired.
Someone in my household is blind or vision impaired.
None of these apply to my household.
Other:
Required
Do you have any pets in your home?
No
Yes
Clear selection
Which description best fits your house?
*
Ranch Style
Bi-Level
Tri-Level
Prefabricated home
Other:
How many stories (above grade) is your house?
*
1 Story
2 Story
3 (or more stories)
Does your house have an attic?
*
Yes
No
Does your house have a basement or crawlspace?
*
Full Basement
Crawl Space or Cellar
No basement
Does your house have an attached garage?
Yes, attached 1 car garage
Yes, attached 2 or more car garage
No garage
Clear selection
What type of roofing material is your roof covered with?
*
Ashpault Shingles
Metal / Tin
Tar
Other:
Describe your roof:
*
Choose
Pitched
Flat
Describe the frame of your house:
*
Choose
Wood frame
Metal / steel
Concrete / masonary
Gas Utilities:
*
Nipsco - Natural Gas
Ceres Solutions - Propane
Other:
Required
Gas Shut Off Location:
Your answer
Electric Utilities:
*
NIPSCO
REMC
Other:
Electric Shut Off Location
Your answer
Water
City / Municipal Water
Well Water
Clear selection
Septic
City / Municipal Septic
Septic Tank
Clear selection
Select any appliance you may have in your house:
*
Gas Water Heater
Electric Water Heater
Gas Range / Stove
Electric Range / Stove
Gas Dryer
Electric Dryer
Other:
Required
Are there other buildings or structures in close proximity to your home, that may be at risk for fire to spread to if your home were on fire?
Yes
No
Clear selection
In the event of a fire in your home, could there be extraordinary dangers to the fire fighters (such as large storage of paint in a garage, storage of ammunition in a gun safe, chemicals, etc.)
Your answer
How many smoke detectors do you have in your home?
1
2
3
4
5
Clear selection
How many carbon monoxide detectors do you have in your home?
1
2
3
4
5
Clear selection
How many fire extinguishers do you have in your home?
1
2
3
4
5
Clear selection
Do you practice escape drills in your home, especially with your children (if applicable)?
Yes
No
Any other information that you would like to add, that may be helpful?
Your answer
Your Home's Needs"
We need a smoke detector
We need a carbon monoxide detector
We need a fire extinguisher
Clear selection
Submit
Page 1 of 1
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. -
Terms of Service
-
Privacy Policy
Does this form look suspicious?
Report
Forms
Help and feedback
Contact form owner
Help Forms improve
Report
