Colestin Rural Fire District

HOMEOWNERS SURVEY for Community Fire Safety Plan

CONTACT INFORMATION

Name:___________________________________________________ Date:____________

Physical Address:___________________________________________________________

Mailing Address:____________________________________________________________

Home Phone:__________________________ Work Phone:__________________________

Cell Phone:____________________________ Email:_______________________________

Names and ages of children:____________________________________________________

_________________________________________________________________________

Names of other adults not specified above but living on the premises:
_________________________________________________________________________

In case of emergency notify:

Name:_______________________________________________________________

Address:_____________________________________________________________

Phone:_______________________________________________________________

Special Needs (blind / invalid / hearing impaired / other):________________________

LIVESTOCK AND PETS  -  TYPE NUMBER LOCATION

Dogs ________ ________________
Cats ________ ________________
Horses ________ ________________
Birds ________ ________________
Cattle ________ ________________
Llamas ________ ________________
Goats ________ ________________
Sheep ________ ________________
Other ________ ________________

Have you made arrangements for your animals’ safety if you are not at home during a fire?
Yes No

Would you like more information on providing for your animals’ safety in the event of a fire?
Yes No

Are you willing and able to move someone’s animals in the event of a fire? Yes No

Do you have a horse/stock trailer and are you willing to help others move their animals?
Yes No

Do you have a fenced pasture where others could keep their livestock in the event of fire?
Yes No


ROADS AND VISIBILITY

Is your address marked and visible at the main road? Yes No
   
At subsequent intersections? Yes No

How far is your home from the main road?________________________________________

Does your driveway have adequate room for a 28 ft fire truck to turn around? Yes No

Are your driveway & access roads to structures at least 12 ft wide? Yes No

Do you have turn-outs for two-way travel? Yes No

Are your driveway and access roads clear 10ft either side of centerline? Yes No

Is there at least a 13-foot vertical clearance along your driveway and access roads?
Yes No

Do you have an alternate escape route if your driveway is impassable? Yes No

Do you know your E.R.A. (Emergency Response Address)? Yes No


BUILDING CHARACTERISTICS

Does your home have fire-resistant roofing? Yes No

Are all vents and openings screened? Yes No

Are your roof and gutters free of debris? Yes No

Are your decks enclosed or screened? Yes No

HAZARDS - (Please fill out with Home Site Locator Sheets available from CRFD)
    Check if you have:

Explosives
Gun powder
Pesticides
Paints / solvents
Portable fuel tanks
Above ground fuel tanks - Cleared of vegetation? Yes No
Oil   Propane   Diesel   Gasoline
Weak bridge or Carrying Capacity unknown
Other, specify_________________________________________________________

CHARACTER OF PROPERTY

Open timber _______ % _______ % flat to gently sloping, 0-20% slope
Dense timber _______ % _______ % moderately steep, 21-40% slope
Patchy scrub _______ % _______ % very steep, +41% slope
Dense scrub _______ %
Grassland _________ %

Do you have many standing dead trees? (2+ average per acre) Yes No

WATER SOURCES  -  TYPE CAPACITY

Well _________
Pond _________
Tank _________
Cistern _________
Hot tub _________
Pool _________

Do you have:

Portable pump ? Yes No

Fire hose ? What size__________ How long________ Yes No

Roof and area sprinklers to wet down home site in event of wildfire? Yes No

WILDFIRE FUEL HAZARD STATUS

Do you have 100 feet of defensible space around your home (brush removed: trees limbed up
at least 8 feet for live limbs, 15 feet for dead limbs, tree limbs at least 10 feet from roofline -
grass mowed - vegetation irrigated to keep it green)?
Yes No

Do you have 100 ft of defensible space around all other structures on your property?
Yes No

Are you interested in a fire safe inspection/consultation for your:

Home ? Yes No
Access roads ? Yes No
Forest land ? Yes No


OTHER COMMUNITY RESOURCES

Do you want to be part of a Neighborhood Phone Tree for use in emergencies (notification
of wildfire, hazardous spills, evacuation etc.)? Yes No

Do you want to participate in small Neighborhood Emergency Response Teams to help insure
that people, pets, valuables are accounted for in the event of a major emergency? Yes No

Do you have a large clear area on your property where people can meet to do a head count in the
event of evacuation? Yes No

Do you have special tools/equipment that you would be willing to operate or lend to reduce the
wildfire fuel hazard in the District? mowers / pruners / chainsaws / slashbusters / dozers / tractors
/ other ? Yes No

Would you like to volunteer some time to make the District better prepared for fire?
Yes No

Do you have a current First Aid card? Yes No

Do you have a current CPR card? Yes No

Are you a licensed medical professional? Yes No If so, specify:

__________________________________________________________________________

Are you willing to provide sandwiches, cookies, coffee etc. for firefighters? Yes No

Do you have any other skills or resources which you are willing to use to help in the event of
wildfire or other emergency?

__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________

Are there specific fire risks in our District that you feel should be considered in our Community Fire
Plan? Do you have suggestions for addressing these risks? Other comments also welcome.

__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________

I hereby release the above information as needed ONLY for emergency purposes to emergency responders and to the CRFD Committee for Fire Plan Development.


_______________________________________________
SIGNATURE & DATE of person completing the form