SAFE & WELL

The Community Fire Safety Check from Gloucestershire Fire and Rescue Service

Name*

Address Line 1*

Address Line 2

Town*

Post Code*

Is your property privately owned or rented*

Private Rented

Telephone No

e-mail address

Do you or anyone in your household show symptoms of COVID-19*

Yes No

Are you self isolating*

Yes No

Comment*
Please include an ideal
time for GFRS to contact
you to arrange a visit

Is anyone in the household over 65*

Yes No Not Applicable

Is anyone in the household under 5*

Yes No Not Applicable

Do you/they live alone*

Yes No Not Applicable

Does anyone in the household smoke*

Yes No Not Applicable

Does anyone in the household have a disability*

Yes No Not Applicable

Please Give Details
e.g. Hearing impairment,
Sight impairment, Mobility,
Long term health
issues, None

Is there any asbestos present in the property*

Yes No Unknown

Do you/they have any working smoke alarms*

Yes No Unknown

Name
Relationship to occupier
Email
Contact number

Has the SU given consent for GFRS to contact them*

Yes No