Hard of Hearing alarm Form

You are submitting this form as a:

Resident / member of the publicFirefighterService provider

Details of residence

Name: *

Address *

Street address *

City *

Postcode *

Unit or apartment number

Contact phone number *

Contact e-mail address *

Comments - for alternate contact information

Level of hearing loss

MildModerateSevere

Can hear a regular smoke alarm?

YesNoNot well

Note for firefighters:

If the resident has any hearing loss, please discuss installing extra standard smoke alarms throughout the house in areas such as bedrooms or outside of bedrooms in hallways.

Test the alarm and gauge how far away they can hear it.

If the resident cannot hear an alarm from a suitable distance, a specialist Hard of Hearing alarm can now be supplied and installed by FRNSW free of charge.

Do you qualify of a Hard of Hearing alarm? *

My Aged CareNDISHomes NSWNone of the above

Please contact your service provider before submitting this form. They may be able to provide a specialised hard of hearing alarm along with other specialised systems for your home.

You can request a free hard of hearing smoke alarm to be installed by Fire and Rescue NSW. Please continue and submit the form.

Submitted by

Company / Station *

Full name *

Delivery Address *

Street address *

City *

Postcode *

Email Address *

Contact number of the person requesting *