Residential Questionnaire

* This information will remain confidential with the North Massapequa Fire Department and not disclosed with any other agency. The primary purpose of this information is to relay vital information to responding firefighter’s in the event of an emergency at your residence. The more accurate and descriptive you are with your responses, the quicker and safer our firefighters will be able to react, assist, and mitigate an emergency at your dwelling. We thank you in advance for your support and understanding with the value of this request and your cooperation with sending this information back. The Chiefs, Officers, and Members of the North Massapequa Fire Department
Name
First Last
Address
Street Address Address Line 2 City State ZIP Code
Phone
Emergency Contact Name
First Last
Emergency Contact Phone
Construction
Type of House
- Split
- Colonial
- Ranch
- In-line Ranch
- Hi-Ranch
- Hi In-Line Ranch
- Cape
- Other - Specify Below
Other Type of House
Number of Floors (Exclude Basement and Attic)
- 1
- 1.5
- 2
- 2.5
- 3
- 3.5
- 4
Basement
- Basement
- Basement Outside Entrance
- No Basement
Attic
- Attic
- No Attic
Apartment
- Apartment (Specify Details Below)
- No Apartment
Apartment Location Details
Describe any dormers or extensions made to home
Explain Layout of Home with as much description as known: (for instance, a split with 2 bedrooms on the second level, and one bedroom on the 3rd landing, unfinished basement)
Unconventional Rooms in Private Dwelling: such as a garage, basement, or other room converted to living quarters. Describe with as much detail as possible.
Other: Anything else that may aid our response efforts, Describe.
Garage
- Detached
- Attached
- No Garage
Utilities
Electric: List all Main and Subpanels controlling the distribution of power within the home and the location of the exterior meter.
Generator
- None
- Side 1
- Side 2
- Side 3
- Side 4
- Manual Transfer Switch
- Automatic Transfer Switch
Electric Vehicle Charging Station: If yes identify location
- None
- Garage (Interior)
- Garage (Exterior)
- Side 1
- Side 2
- Side 3
- Side 4
Solar Panels (Describe location of exterior shutoff)
- None
- Side 1
- Side 2
- Side 3
- Side 4
Gas (Describe location of main shutoff)
- Interior
- Exterior
- Side 1
- Side 2
- Side 3
- Side 4
Water (Describe location of main shutoff)
- Side 1
- Side 2
- Side 3
- Side 4
Fixed Propane Cylinders
- Side 1
- Side 2
- Side 3
- Side 4
Fireplace
- Conventional Wood
- Gas
- Other, describe below
Fireplace Details - Other
Sprinklered Occupancy
- Sprinklered Occupancy
- No Sprinklers
Special Attention
Hazardous Materials: Please list (significant quantities only) hazardous materials. Write the amount of each product and the location of where it is stored.
Handicapped or Special Needs Occupant: Describe age, handicap, special needs and , location of occupant in house
Animals: Describe
Phone
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Residential Questionnaire

Construction

Utilities

Special Attention