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Home Fire Safety Check

Home Fire Safety Check Form

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Home Fire Safety

Home Fire Safety Check

Home Fire Safety Check Form

"*" indicates required fields

This form is for our partner agencies use only.
All other referrals should be made via our public Safelincs referral form.

General Data Protection Regulation (GDPR)

All data supplied to NIFRS will be held and processed in accordance with GDPR.*

Please tick this box to confirm you permit NIFRS to hold and process your information.

Has the occupier agreed to a Home Fire Safety Check from NIFRS?*

Please tick this box to confirm the occupier has agreed to a Home Fire Safety Check.

Stop. Please make contact with the occupier and seek their agreement before continuing. After consent has been obtained, please return to submit their details.

You have confirmed you are making a referral on behalf of an agency. Please tell us which agency*

If other – please specify*

Partner Agency Contact Number*

Partner Agency email Address*

NIFRS email Address*

Reason(s) for the Referral:*

Aged 50 or over

Alcohol

Dementia

Drugs/Medication

Hoarding

Impaired Mobility

Learning Disability

Living Alone

Mental Health

Physical Health Condition

Sensory

Smoking

Other

If other – please specify*

Occupier Details

Name*

First Name Last Name

Phone Number*

Email Address

Address*

Street Address Address Line 2 City Post Code

Alternative Point of Contact Details

Please tick this box if you would like to provide an alternative point of contact to assist with arranging the visit?

Yes

Name*

First Name Last Name

Phone Number*

Email Address

Relationship*

Does the property have any working smoke alarms?*

Yes

No

Unknown

If there is any additional information that will assist us, please provide this below:

Stop fire

Get a free Home Fire Safety Check

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