Resident Survey :: Freeport Fire Department

Resident Survey

The purpose of this form is to collect information to be used in the Freeport Fire Departments Emergency Database for Responses and Emergency Notifications only. No information will be released to any other person or agency. If the Fire Department responded to your residence for an Alarm please fill out the comments section at the bottom so we can strive to better serve you.

Resident or Business Name Required

Address

Location Phone Number

Cell Phone

Are there people with special needs at this location? Required

Yes

If yes, please explain condition and location in residence.

Are there any special hazards at this location? (ie: dangerous dog, hazardous materials, etc.) Required

Yes

If yes, please explain condition and location in residence.

Emergency Contact Name: Required

Emergency Contact Phone # Required

Does Emergency Contact have access to location?

Yes

Comments

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Resident Survey