Pre-Plan Information

Last year, the Terryville Fire Department responded to over 2700 alarms. As each year goes by, our call volume increases and we respond to many more locations than the prior year.  We expect our call volume to increase again in 2013.  We are asking for your help in our effort to preplan our response in the event we are called to your home or business for an emergency.  


Below is our online Pre-Plan Form.  You will find that all of the information that we ask for can be essential in the event of a fire or medical emergency at your home or business.  Please do not ignore this.  If you have not already submitted a form, we urge you to do so as soon as possible!


Any information you provide is designed for our use only to assist us in responding to your emergency.  We will not share your information with any other agency.  Please help us help you.  In addition, please spread the word to your friends and neighbors t submit a form as well.  Thank you in advance for you cooperation in this very important matter.


Pre-Plan Form

OCCUPANT INFORMATION
 
Household / Company Name:
 Address:  
 Phone #:
 

 Key Holder Name & Phone #:  
 Key Holder Name & Phone #:  
 Fire Alarm Monitoring Company & Phone #:  
Bldg Maintenance Phone #:




CHILD / SPECIAL NEEDS INFORMATION (RESIDENTIAL ONLY)

 
Please provide us with the following information as it relates to young children and persons with special needs residing in your home: 
 Name / Date of Birth / Location in home:  


 UTILITY LOCATION INFORMATION

(Describe where in your home or builfing the applicable items are located)
 Fire Sprinkler shutoff:  
 Standpipe shutoff (Commercial only):  
 Fire Alarm panel:  
 Electric shutoff:  
 Water shutoff:  
 Gas shutoff:  
 Oil shutoff:  
 Heat / AC shutoff:  
 Solar shutoff:  
 Knox Box location (Commercial only):  


 BUILDING & GROUNDS INFORMATION

How would you describe your building?   Single Family Home
Multi-Family Home
Apartment
Condominium
Commercial
 If you checked Commercial, please decribe:  
 Construction type (select all that apply):  Wood
Brick
Block
Cement
 Number of floors (not including basement):  


 Does your building have a basement?  
YES

If yes, what type of basement?   Finished
Unfinished
Crawl
 If yes, is there an outside entrance?  
YES
Does your home have a garage?
 YES
 If yes, what type of garage?  Attached
Detatched
1-car
2-car
3-car
 Width of home/building:
 

 Length of home/building:  


 # of stories:
 

 Do you store more than 20 lbs of propane?  
YES

 If yes, where is the propane stored?:
 

Do you have a pool?   
YES

 If yes, what type of pool?
 Above-ground
In-ground

 Are there any apartments within your home?
 YES

 If yes, please advise how many and where the entrances are located::  
 Do you own a dog?
 YES

 Any other hazards such as stored chlorine, fertilizers, etc., can be provided here.  In addition, please advise us if there is anything else that you would like us to know about your home or anything you think may be hazardous to responding personnel:  
 

Thank you for taking the time to complete this survey.

The information provided on this form will help us plan our response to your home or building in the event of an emergency.


 
We will not share your information with any other agency