Wisconsin Templates
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Outline

The Wisconsin F 60953 form serves as an essential tool for ensuring fire safety within adult family homes. This guide assists applicants, licensees, and surveyors in evaluating compliance with fire safety requirements outlined in the Wisconsin Administrative Code, specifically chapter DHS 88. While the use of this form is not mandatory, it provides a comprehensive checklist that addresses critical aspects of fire safety. Key areas covered include the presence of hazards, the adequacy of exit routes, and the maintenance of smoke detection systems. The form also emphasizes the importance of having a written evacuation plan, conducting regular fire drills, and ensuring that all residents, especially those with mobility challenges, can safely exit the home in case of an emergency. Additionally, it outlines requirements for fire extinguishers and the proper maintenance of heating systems, contributing to a safer living environment for residents. By completing this form, licensees can better protect the individuals in their care, fostering a commitment to safety and well-being.

Steps to Filling Out Wisconsin F 60953

Completing the Wisconsin F 60953 form is an essential step in ensuring that your adult family home meets fire safety standards. This form helps you assess various safety requirements that protect residents and staff. Below are the steps to fill out the form accurately.

  1. Begin by entering the Name of your facility at the top of the form.
  2. Fill in the Facility Address, including the city, state, and zip code.
  3. Next, write the Name of the Licensee and the County where the facility is located.
  4. Indicate the Name of the Person Completing This Form and the Date Completed using the format MM/dd/yyyy.
  5. Proceed to the FIRE SAFETY section. For each question, mark YES or NO based on your assessment.
  6. Ensure that you answer all 41 questions in the FIRE SAFETY section, considering the specific requirements outlined.
  7. If applicable, refer to the DQA forms F-62372 and F-62373 for evaluations and assessments mentioned in the questions.
  8. After completing the FIRE SAFETY section, check the SMOKE DETECTION SYSTEM section. Again, mark YES or NO for each of the 8 questions.
  9. Next, move to the FIRE EXTINGUISHER section and answer the 7 questions by marking YES or NO.
  10. Review your answers to ensure accuracy and completeness before submitting the form.

Once you have filled out the form, keep a copy for your records. This documentation can be invaluable during inspections or evaluations. It not only shows compliance but also demonstrates your commitment to the safety and well-being of your residents.

Key takeaways

Here are some important points to consider when filling out and using the Wisconsin F 60953 form:

  • This form is a guide to help ensure compliance with fire safety requirements in adult family homes.
  • Completing the form is not mandatory, but it is highly recommended for safety.
  • Provide accurate information about the facility, including the address, licensee name, and the person completing the form.
  • Check for hazards in the home. It should be uncluttered and free from dangerous substances.
  • Ensure that there are at least two means of exit from the home that are unobstructed.
  • Have a written evacuation plan in place and review it with new residents immediately after placement.
  • Conduct fire drills at least twice a year, documenting each drill's date and evacuation time.
  • Maintain smoke detectors and fire extinguishers in good working condition, ensuring they are inspected regularly.

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Documents used along the form

The Wisconsin F 60953 form serves as a crucial guide for ensuring fire safety in adult family homes. Along with this form, several other documents are commonly utilized to support compliance and enhance safety measures. Here is a list of those documents, each serving a specific purpose in the overall safety framework.

  • DQA Form F-62372 - This form is used for the CBRF Resident Satisfaction Evaluation. It assesses whether a new resident can evacuate the home without assistance within two minutes, ensuring that safety protocols are tailored to individual needs.
  • DQA Form F-62373 - This document is the Resident Evacuation Assessment. It is used annually to evaluate each resident's evacuation time, helping to identify any necessary adjustments to safety plans based on the resident's capabilities.
  • Fire Safety Evacuation Plan - This written plan outlines the immediate and safe evacuation procedures for all occupants in case of a fire. It is essential for ensuring that everyone knows what to do during an emergency.
  • Affidavit of Residency: When verifying residency in Florida, it's important to refer to the essential Affidavit of Residency form guide to fulfill all necessary legal requirements.
  • Fire Drill Documentation - This includes records of semi-annual fire drills conducted with all household members. Documentation should detail the dates and evacuation times for each drill, demonstrating compliance with safety regulations.
  • Inspection Reports - These reports document the regular inspections of smoke detectors, fire extinguishers, and heating systems. They ensure that all safety equipment is functional and meets the required standards.

Utilizing these documents alongside the Wisconsin F 60953 form will help ensure a safer living environment for residents. Proper documentation and adherence to safety protocols are key to maintaining compliance and protecting the well-being of all individuals in the home.