Are you completing the correct form?

This form is to be completed by a referring agency for example a Primary Care Trust, it is not to be completed by individuals.

Multi agency referral

It is our intention to work with other agencies to identify target areas within Hampshire. These agencies will be able to refer vulnerable groups for a home safety visit by a representative from the Fire Service. Their home will be assessed for fire risk, with a view to fitting free smoke detector alarms if required. We will also discuss the putting together of a home escape plan and provide education advice to lower fire risk.

Before completing this form

Please take a look at our multi agency referral checklist, this will help you to decide whether the person you are referring is eligible for a home safety visit.

(*) indicates a required field.

Referrer's details...

Name:(*)

Organisation:(*)

Telephone:(*)

E-mail:(*)

Referral code:

Occupier's details...

Name:(*)

Address:(*)

Postcode:(*)

Telephone:(*)

Other details...

Has permission for the visit been given by the occupier? This needs to be obtained as HFRS has no right of entry in order to carry out a home safety visit.yes no

Will a carer/responsible person be required to be present at the visit? If yes, then the visit will be arranged through the carer/responsible person.yes no

If care is provided to the occupier who commissions/pays for the care?

E-mail of care payee:

Is there any additional information that would assist HFRS in this visit, eg HFRS should not attend alone?

Hampshire Fire and Rescue Service supports the objectives of the Data Protection Act 1998 and is registered as a data controller. Information which you provide will be governed by the requirements of the Data Protection Act 1998 and may be processed by the Service in the performance of its statutory duties or for purposes required by law. More information is available at www.hantsfire.gov.uk/dataprotection.

This form will deliver to Community Fire Safety

Hampshire Fire and Rescue Service will only use the information submitted for the purposes of undertaking home fire safety visits and providing safety education. It will only be disclosed to other parties to assist in this purpose. All data will be processed in accordance with the Data Protection Act 1998.