Before making a referral complete a home safety visit assessment make sure you have the occupier’s permission to refer to the fire service (a refusal may need to be considered as a safeguarding issue) if you are having a problem submitting the web form below, please download the home safety visit referral form and email your completed form to firstname.lastname@example.org, or give us a call on 023 8062 6751 weekdays 9am - 5pm. Indicates mandatory fieldsMake a home safety visit referralAbout the occupierAddress of premises: Postcode of premises: Name of occupier: Occupier telephone number (including STD code). Please enter without spaces: Alternative telephone number of friend or relative, if occupier hearing impaired. Please enter without spaces: Suitable time to contact occupier: Agency detailsIf you are referring on behalf of someone else do you have their consent YesNo If consent has not been given, has social worker or care manager referred under duty of care? Please expand on reasons why: Your name and contact details: Your email address: Agency details: Suitable time to contact you regarding a joint visit: AssessmentQuestion 1: In your opinion are there signs of carelessness with smoking materials including burn marks around the home and on bedding? YesNo Question 2: Does the person you’re referring present a fire risk when cooking? YesNo Question 3: Does the person you are referring have a physical impairment or cognitive impairment which would prevent or hinder them from escaping a fire in an emergency? YesNo Question 4: Do they have a sensory impairment (sight/hearing/touch or taste) which may put them at more risk of having a fire? YesNo Question 5: Does the person you are referring use substances (alcohol and/or drugs) which may affect their escape in the event of a fire? YesNo Question 6: Are you aware if the person you are referring uses oxygen within the home? YesNo Question 7: In your opinion does the person you’re referring collect and store items around the home which may be considered hoarding? YesNo Question 8: Does the person you are referring live alone? YesNo Question 9: In your opinion do they have inadequate means for raising the alarm in the case of fire (ie no smoke detection)? YesNo 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.