Form Test

General Data Protection Regulation
All data supplied to Northern Ireland Fire & Rescue Service will be held and processed in accordance with the General Data Protection Regulation (GDPR).
*
- Please tick this box to confirm you permit NIFRS to hold and process your information.
We would like to ask you some questions about the person who lives in the property to determine their eligibility to receive a Home Fire Safety Check.
Eligibility Criteria below – Please tick those that are relevant.
Please select all that apply.*
- Is anyone aged 50 or older?
- Does anyone have a disability or impaired mobility - (includes people who have an impairment or health condition that would impact on their ability to acknowledge or respond to an emergency in the home)
- Referral from an Agency or the occupant receives assistance from a visiting Agency on a regular basis to help with day-to-day tasks?
- None of the above.

Name*
First Last
Phone*
Email
Address*
Street Address Address Line 2 City ZIP / Postal Code
Does the property have any working smoke alarms?*
- Yes
- No
If Yes, how many?
If there is any additional information that will assist us, please provide this below:
If you have an agency referral, please check the box. If not, please click to submit.
I confirm that I have an agency referral.

You have confirmed you are making a referral on behalf of an agency. Please tell us which agency:*
- Pharmacy Plus
This form is for agency use only. If you are not from an agency, then please disregard this form. Please make contact with the occupier and seek their agreement before providing details to NIFRS. After consent has been obtained, you may return to submit their details.
Has the occupier agreed to a Home Fire Safety Check from Northern Ireland Fire & Rescue Service?*
- Yes
- No
If no, skip agency details and submit.
Agency Contact Number*
Agency Email*
Agency Address*
Street Address Address Line 2 City County Postcode
Reason for the Referral:*
Name
This field is for validation purposes and should be left unchanged.