Published28 November 2023 Last updated28 November 2023 You must have JavaScript enabled to use this form. Are you requesting of behalf of another person? No Yes Relationship to the referee Professional Parent Son Daughter Wife Husband Friend Other… Enter other… Referrer's Details Name Referrers Agency Name (If applicable) Email Phone Address Address 2 City/Town Post Code The person who this request is made on behalf of understands that the home safety visit provided by East Sussex Fire & Rescue Service is completely FREE of charge and consent been given. ____________________________________________________________________ Who is this Home Safety Visit For? Name Phone Address Address 2 City/Town Post Code Answer these questions as best you can. This will help us to understand whether we need to send a specialist member of our team. All of these are factors which may increase the risk of fire(please tick all that apply) 80 Years or Over 65 years or older Live alone Is there anyone in premises with pacemaker? Reduced mobility/immobile Long-term medication/sedatives Occupier has no working smoke alarms Previous fire incident History of fire setting (starting fires) in home Property Privately Owned Property Privately Rented Sight impaired Smoker Deaf, deafened or hard of hearing Is there anyone in premises with Epilepsy? A single parent (with one or more children 0-5 years age) Heavy alcohol consumption Is someone a victim of arson or threats of arson? No Yes Please provide as much information as possible about the arson or threats of arson Is someone a victim of domestic violence and/or hate crime? No Yes Please provide as much information as possible about the domestic violence and/or hate crime? Is the property owned by a Housing Association/Council? No Yes Housing Association/Council Details Does anyone at the property suffer any mental health issues (e.g. Dementia) No Yes Details of mental health issue Is there hoarding on the premises? No Yes Clutter Rating Any additional comments you think might be helpful In this section Home Safety Visits Home Safety Visit Request Form Online home fire safety check Care Providers Fire Safety Scheme 6-Steps to a safer home Fire safety advice in other formats and languages More home safety advice Seasonal Safety Previous Home Safety Visits Next Online home fire safety check
