SAFE & WELL

The Community Fire Safety Check from Gloucestershire Fire and Rescue Service

Complete the form below to request a Safe and Well visit or alternatively call 0800 180 41 40 and speak to our Community Safety Team

All fields below marked * must be completed before the data will be submitted

Service Users Details

Name*

Address Line 1*

Address Line 2

Town*

Post Code*

Is your property privately owned or rented*

Private Rented

Telephone No

e-mail address

Comment*
Please include an ideal
time for GFRS to contact
you to arrange a visit
or details of a second contact (if applicable)

Is anyone in the household over 65*

Yes No Not Applicable

Is anyone in the household under 5*

Yes No Not Applicable

Do they live alone*

Yes No Not Applicable

Does anyone in the household smoke/vape*

Yes No Not Applicable

Does anyone in the household have any Disabilities/Health Concerns - select all that apply

None

Unknown

Alcohol Dependence causing drowsiness

Breathing Difficulties or uses medical oxygen

Dementia / Alzheimers

Hearing Impairment

Learning Disability

Mental Health Condition

Mobility Concerns

Other Physical Health Condition

Please Give Details
if Other Physical
health issues
is selected

Prescription Drugs causing Drowsiness

Recreational Drugs

Visual Impairment

Additional Information

Is there any asbestos present in the property*

Yes No Unknown

Do they have any working smoke alarms*

Yes No Unknown

Are they reporting a faulty smoke alarm*

Yes No Unknown

Does anyone in the household have a Care Support Package in place*

Yes No Unknown

Please supply name and contact details of Carer/Care company

Has the property had a fire in the last 3 years*

Yes No Unknown

Is the property hoarded L4 to L9 or have obstructed exits*

Yes No Unknown

Are you requesting a visit on behalf of someone else? If so, please provide:

Name
Relationship to occupier
Email
Contact number

Has the SU given consent for GFRS to contact them*

Yes No