Service Acknowledgment Form Type


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What are the exact words found on the top of the page?


Home Address*


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Example: 2025 E Street NW
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Mark 'NA' if not applicable
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(5-digits) Example: 20006
Address Not Verified
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Must click 'verify address' to auto-populate

Services Provided*


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Enter the Number of New 10-Year and 9-Volt Alarms Installed
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Enter the Number of New Bed Shaker Alarms Installed for Individuals Who are Deaf or Hard of Hearing
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Enter the number of 9-volt batteries replaced in pre-existing alarms
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Home Fire Safety Checklist
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If yes, select hazard
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Reference Red Cross/Partner Printed Name
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(mm/dd/yyyy)

Initial Assessment Upon Visit*


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For people served 15 or more, check 14 and leave a comment in the additional notes section.

Partner Reporting Fields*


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Track National Partner Participation
If more than one, separate by commas. Enter RCC for Red Cross Corps
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Select all that apply.

Region Designated Reporting Fields

Regions may direct volunteers to report on additional aspects of the campaign. These two fields can be used to collect and track this data.

Information for Future Follow Up*

Choose one or more of the following

xxx-xxx-xxxx
xxx-xxx-xxxx

Administrative Section*


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