DSP-SFMG 008 (Rev. 07/2014) PAGE 1 of 2
STATE OF MARYLAND
DEPARTMENT OF STATE POLICE
OFFICE OF THE STATE FIRE MARSHAL
http://mdsp.org/firemarshal
FOSTER CARE / ADOPTIVE HOME SURVEY REQUEST
REQUESTOR
NAME:
DATE OF REQUEST:
REQUESTING
AGENCY:
ADDRESS:
CITY:
STATE:
ZIP CODE:
PHONE:
EMAIL
ADDRESS:
LICENSING AGENCY (Check one):
Department of Health and Mental Hygiene
Department of Juvenile Services
Department of Human Resources
Other (Specify):
In order to comply with licensing regulations for FOSTER CARE / ADOPTION HOMES, we are requesting a fire safety survey for the residence listed below:
NAME:
ADDRESS:
CITY:
STATE:
ZIP CODE:
HOME PHONE:
CELLULAR PHONE:
SPECIAL INSTRUCTIONS OR DIRECTIONS:
INITIAL SURVEY
DUE DATE:
RENEWAL SURVEY
NOTE: The Office of the State Fire Marshal
will establish an appointment for the survey.
FOR OFFICE OF THE STATE FIRE MARSHAL USE ONLY:
NO VIOLATIONS NOTED AT TIME OF SURVEY
VIOLATIONS NOTED ON ATTACHED SURVEY SHEET
DATE OF SURVEY:
PRINTED NAME OF INSPECTOR
SIGNATURE OF INSPECTOR
I CERTIFY THAT THE VIOLATIONS NOTED ON THE ATTACHED SURVEY SHEET HAVE BEEN CORRECTED:
DATE:
PRINTED NAME OF CASE WORKER
SIGNATURE OF CASE WORKER:
DSP-SFMG 008 (Rev. 07/2014) PAGE 1 of 2
OFFICE OF THE STATE FIRE MARSHAL
AREAS OF RESPONSIBILITY
All areas of the form must be completed in their entirety and legible. Forms not complete or legible will be
returned for resubmission.
Completed forms must be delivered to the appropriate OSFM office as listed below.
COUNTIES: ALLEGANY, GARRETT, WASHINGTON
Office of the State Fire Marshal
Maryland State Police, Western Operations Center
18345 Colonel Henry K. Douglas Drive, Suite 240
Hagerstown, MD 21740
msp.osfmwro@maryland.gov
Phone: 301-766-3888
Fax: 301-766-3889
COUNTIES:, CARROLL, CECIL, HARFORD
Office of the State Fire Marshal
Mary E. W. Risteau Multi Service Center
2 South Bond Street, Suite 401
Bel Air, MD 21014
msp.osfmnero@maryland.gov
Phone: 410-836-4844
Fax: 410-836-4845
COUNTIES: CALVERT, CHARLES, ST. MARY’S
Office of the State Fire Marshal
Louis L. Goldstein Multi Service Center
200 Duke Street, Suite 1500
Prince Frederick, MD 20678
msp.osfms[email protected]
Phone: 443-550-6820
Fax: 443-550-6822
COUNTIES: CAROLINE, KENT, QUEEN ANNE’S,
TALBOT
Office of the State Fire Marshal
301 Bay Street- Lower Level
Easton, MD 21601
msp.osfmuero@maryland.gov
Phone: 410-822-7609
Fax: 410-819-0485
COUNTIES: DORCHESTER, SOMERSET, WICOMICO
Office of the State Fire Marshal
201 Baptist Street
Salisbury, MD 21801
msp.osfm[email protected]
Phone: 410-713-3780
Fax: 410-713-3790
