Form test Introduction and explanation Please complete this form Blank Form (#4) Notify Name of blockFlat numberFull name of resident Please indicate your age– Select –under 30 yrsbetween 31 & 40yrsBetween 41 & 50yrsBetween 51 & 60 yrsBetween 61 & 70yrsover 71yrsHow many people live at your address?Does any adults living at the address have a disability? Yes – please answer the next question NoIf yes, please indicate the type of disability sight hearing physicalPlease use this space to provide any other relevant information regarding anyone in your hopsehold.Can all adults in your household get to the front door unaided? Yes No SometimesCan all adults in your household open the front door unaided? Yes No SometimesIs anyone in your household on medication or receiving treatment that might prevent them from reacting to and emergency? Yes No Sometime If yes, please tell us a little more/Is the escape route in your home obstructed by furniture, storage a mobility scooter or anything else? Yes No SometimesDoes anyone in your household smoke or use e-cigarettes? Yes No Submit Form
