Date Sent to OIC:     Date Received by OIC:     Date Returned to Fire Prevention:

Carrollton Fire Department

Public Education Request Form

SECTION 1 – To be filled out by Fire Prevention.  Use ‘Tab’ key to move from field to field.

Date of Call: Received by:

Program Date: Time: Station/Shift: OIC:

Group / Association:

Contact Person: Phone Number:

Location / Address of Program:

Group Type/Characteristics (age/special ed):

Estimated Number:  Adults - Children -

Program Type:

     CPR                                                                                     School Visit:

     Equipment Display                                                               Fire Alarm Systems / Smoke Alarms

      Fire Drill                                                                               Station Tour

      Fire Extinguisher Demo                                                       Video / Film:

      Fire Extinguisher Training                                                    Workplace Fire Safety / First Aid Training

      First Aid                                                                               Fire Sprinkler System: Residential / Commercial

      Program by Staff                                                                  Other:

Materials Needed:

      Brochure Type:       Home Escape Grids

      Coloring Books / Sheets                                                      Stickers / Rulers / Pencils / Pens

      Extinguishers Needed                                                         Video(s):

      Extinguishers Provided                                                        Other:

      Fire Extinguisher Barrel

SECTION 2 – To be filled out by OIC.  Use ‘Tab’ key to move from field to field.

***  Complete  lower  section  after  program  &  return  to  Fire Prevention  ***

Firefighter(s) assigned to program(s): Date:

Delivered as planned? Yes No (If no, please explain in Comments Section below)

Size of Audience:               # of Preschool (1 – 4 yrs)                          

(estimate if needed)            # of Elementary School (5 – 10 yrs)          

                                          # of Middle School (11 – 13 yrs)                

                                          # of Jr. High School (14 – 15 yrs)              

                                          # of High School (16 – 17 yrs)                   

                                          # of Adults (18 – 64 yrs)                           

                                          # of Elderly Citizens (65 + yrs)                  

# of Personnel:             On-duty / In-Service                                          Off-Duty / Overtime                       

                                    On-Duty / Out-of-Service                                   Admin Staff                                   

Length (time) of Program:

Comments: