Download to PDF

Installation/Inspection Report

Smoke Detector Installation/Inspection Report

 

 

Name _____________________________________________________________________________
                              First                                   MI                                           Last

Address ___________________________________________________________________________
                     Street Address                              City                                  State               Zip

Reason for Being at Location:
 Fire Emergency
 Citizen Request
 Medical Emergency
 Self Initiated
 

Home Equipped with Correct Number of Smoke Alarms:      Yes       No

Number of Smoke Alarms/Type:    Battery___________       Wired___________       Both_________

Number of Alarms Tested/Inspected:   ___________________

Test/Inspection Results:

Alarms Location:____________________      OK       Need Batteries       Replace Alarm
Alarms Location:____________________      OK       Need Batteries       Replace Alarm
Alarms Location:____________________      OK       Need Batteries       Replace Alarm
Alarms Location:____________________      OK       Need Batteries       Replace Alarm
Alarms Location:____________________      OK       Need Batteries       Replace Alarm
Alarms Location:____________________      OK       Need Batteries       Replace Alarm
Alarms Location:____________________      OK       Need Batteries       Replace Alarm
Alarms Location:____________________      OK       Need Batteries       Replace Alarm

Reason Smoke Alarms Malfunctioned or Not Working:

No Battery__________   Dead Battery__________   Electric Disconnected__________   Other________

Missing or Disabled Smoke Alarms___________________

 

Fire Department Officer Signature________________________________________________________

Date of Request: _____/_____/_____