Name of Person completing the form *

First Name

Last Name

Name of additional trainers

leave blank if only one trainer

First Name

Last Name

Start Date of Training *

MM

DD

YYYY

End Date of Training *

can be the same as the start date

MM

DD

YYYY

Type of Audience *

Please describe your audience:

School

Community Members

Market

Church

Mosque

Temple

Home

Business

Junior Firefighter Program

Parent Group

Community Organization

Non-Government Organization

Conference

Social Media (education only)

Media: Radio

Media: TV

Media: Newspaper Article

Other: Describe

Lessons Taught *

Preventing Fires In our Homes

Preventing Cooking Fires

Preventing Electrical Fires

Preventing Gas Cylinder Fires

Stop Drop and Roll

Get Low and Get Out/ Get Low and Go

Contacting the Fire Brigade/Department

Evacuation Drills in the Home

School Evacuation Drills

Use of Fire Extinguishers

Preventing Fires from Candles and Lamps

Preventing Bush Fires

Responding to Bush Fires

Use of Smoke Detectors

CPR

First Aid

Other - describe:

Improved Confidence in Fire and/or EMS Services *

As as result of the training - do you believe that the participants have an increased confidence in the ability of fire and/or EMS providers to respond effectively in their community?

Yes

No

Unsure