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T, licensee, and surveyor to determine compliance with the fire safety requirements of DHS 88, Wisconsin Administrative Code. This form is not mandatory. Name Adult Family Home Address City State Name - Licensee County Name - Person Completing This Form Zip Code Date Completed Yes No FIRE SAFETY 1. Is the home free from hazards and kept uncluttered and free of dangerous substances? DHS 88.05(3)(b) 2. Does the home have at least two (2) means of exiting that provide unobstruct.

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