Date Evaluated:
SECTION 1 – Home Information
Homeowner Name(s):
Location:
Tax Map ID:
Latitude:	Longitude:
Fire Department Jurisdiction:
No. of Acres:
SECTION 2 – Wildfire Hazard Rating Calculation
SITE Hazard Rating	+	STRUCTURE Hazard Rating	+	HAZARD MITIGATION Hazard Rating	=	OVERALL WILDFIRE HAZARD RATING
+	+	=
SECTION 3 – Site Hazard Rating	Rating
HOME IDENTIFICATION: Is the mailbox and address clearly marked? Mailbox, home or 911 address is clearly marked with 4-inch reflective numbers Mailbox, home is marked but difficult to read (small letters, obstructed view, only visible from one direction) Address is not marked	0 5 10
DRIVEWAY CHARACTERISTICS: Is the driveway clear enough for fire trucks and emergency vehicles?
Is driveway at least 12 feet wide with 15 feet of vertical clearance? Yes No	0 10
Is driveway at gated? No Yes	0 10
If the driveway is gated, is the gate 30 feet or more from the road? Yes No	-5 0
If the driveway is gated, is the gate locked? The gate is not locked The gate is locked but able to be unlocked by emergency responders The gate is locked and unable to be unlocked by emergency responders	-5 -5 0
TYPE OF GROUND COVER: What is the primary type of ground cover within 30 feet of the structure? Sand, Gravel, etc (Non-combustible) Grasses up to 6 inches tall Grasses 6 -12 inches tall Grasses greater than 12 inches tall Shrubs with leaves Shrubs with needles	0 2 4 6 3 5

SURROUNDING TREES: How many and what type trees are next to your home?
Select the ONE which best describes the type of trees surrounding your home to use for rating your home’s fire risk (do not rate on all three).	Hardwoods (trees with leaves) No trees within 30 feet 10 trees within 30 feet 10-20 trees within 30 feet 20+ trees within 30 feet	0 2 3 4
Conifers (trees with needles) No trees within 30 feet 10 trees within 30 feet 10-20 trees within 30 feet 20+ trees within 30 feet	0 3 6 10
Mixed Hardwoods and Conifers No trees within 30 feet 10 trees within 30 feet 10-20 trees within 30 feet 20+ trees within 30 feet	0 3 4 6
LANDSCAPING: What plants, shrubs and trees are within your yard?
Are plants clear of structures? Shrubs are at least 5 feet from structures Shrubs are less than 5 feet from or are in direct contact with structures	0 10
What mulch material is used in your landscaping? A non-flammable materials (i.e. pea gravel, lava rock or chunky bark) A flammable material (i.e. shredded bark)	0 10
Are overhanging limbs clear of structures? Overhanging limbs are trimmed to a height 10 feet or above structures Overhanging limbs are less than 10 feet from structures	0 10
PERIMETER:
Is firewood clear of all structures? Firewood is at least 30 feet from structures Firewood is stacked on porch or against home	0 5
Are gas/propane tanks clear of all obstructions and structures? Gas/propane tank is more than 30 feet from the home Gas/propane tank is less than 30 feet from the home Gas/propane tank is obstructed with overgrown brush	0 5 10
Are storage sheds and outbuildings equipped with accessible tools? Storage shed and outbuildings are equipped with a rake, shovel, metal ladder and hose which are readily accessible Storage sheds and outbuildings are not equipped with tools	0 10
Where are storage sheds and outbuildings? Outbuildings are not within 20 feet of the home Outbuildings are within 20 feet of the home	0 5
BRUSH PILES: Where are brush piles located on your property? None Located 0 to 3 feet from structure Located 3 feet to 30 feet from structure Located more than 30 feet from structure	0 6 3 2
FLAMMABLE MATERIALS STORAGE: Where are flammable materials such as gas cans, paint, etc. stored? None Stored in shed or garage located more than 20 feet from the main structure Stored in shed or garage located less than 20 feet from the main structure	0 5 10
OPEN BURNING: Do you practice open burning on your property site? No Yes	0 3
TOTAL SITE HAZARD RATING

SECTION 4 – Structure Hazard Rating	Rating
ROOFING MATERIALS: What materials were used for the roof of your home?
Metal or Tile Asphalt Shingles or Rolled Roofing Wood (cedar shingles)	0 3 6
GUTTERS AND EAVES: Are gutters and eaves clear of debris?
Gutters are cleaned of debris and eaves are boxed Gutters are not cleaned of debris but eaves are boxed Gutters are not cleaned of debris and eaves are not boxed	0 5 10
ATTIC VENTS: Are attic vents covered with ⅛-inch mesh screening? Yes No	0 5
FOUNDATION: What type of foundation does your home have? Enclosed (Fireproof, i.e., concrete, metal) Enclosed with wood sheeting Open	0 3 5
EXTERIOR WALL MATERIALS: What are the exterior walls of your home made of? Brick, Stone or Metal Vinyl or Wood	0 4
WINDOWS: What types of windows are in your home? Double pane or tempered glass Single pane glass	0 4
FENCING: If you have fencing, how is the fencing situated? Wood fencing or trellis is located at least 10 feet from the home or is made of non-combustible material Wood fencing or trellis is located less than 10 feet from the home or is in direct contact with the home	0 5
DECKS: Do you have decks and how are the decks situated? No decks Yes, there are decks and they are enclosed underneath Yes, there are decks and they are open underneath	0 5 10
TOTAL STRUCTURE HAZARD RATING
SECTION 5 – Hazard Mitigation (Reduction) Factors (choose all that apply)	Rating
SITE: Trees pruned up to 6 feet within 30 feet of your home Lot cleared of brush within 30 feet of your home Grass kept watered and short within 30 feet of your home Leaves/Needles raked within 30 feet of your home 3 feet of gravel or non-flammable material adjacent to structure	-2 -2 -2 -2 -1
STRUCTURE: Decks/porches are cleared of debris. Regularly cleaned roof Non-flammable skirting on decks Clear of flammable material against structure	-2 -2 -2 -2
OTHER: Useable water supply nearby Fire fighting equipment available (hose, ladder, shovel, rake etc) Telephone or radio available to call for help Burn barrel/incinerator to standard	-5 -1 -1 -2
TOTAL HAZARD MITIGATION (REDUCTION) FACTORS

SECTION 6 – Wildfire Hazard Rating
What does the Wildfire Hazard Rating number mean?
Using the Wildfire Hazard Assessment, the highest possible rating is 60 points. Woodland homes can be divided into the following four risk categories:
Low Risk:	Total Wildfire Risk Rating is 0 - 10 points
The chances of your home surviving a wildfire are GOOD. Little is needed to improve your situation. Keep up the good work!
Moderate Risk:	Total Wildfire Risk Rating is 11 - 20 points
The chances of your home surviving a wildfire are FAIR. Some Minor improvements will make your home more fire resistant. Check the areas on the form in which you scored poorly.
High Risk:	Total Wildfire Risk Rating is 21 - 40 points
The chances of your home surviving a wildfire are NOT GOOD. Improvements are necessary. Some improvements in structure and site are necessary.
Extreme Risk:	Total Wildfire Risk Rating is More Than 40 points
Your home MAY NOT SURVIVE if a wildfire passes through the area. In fact, a fire could even start on your property. Take a serious look at your property and make improvements. If you don't, you may be facing disaster. You'll find that even small changes could make the difference between losing or saving your home.
HAZARD is defined as the potential fire behavior based on physical fuel characteristics. RISK is defined as the probability of fire occurrence determined by the number, presence and activity of potential ignition sources. This form may be used to evaluate your individual home and determine the level of wildfire risk. It covers roughly one-half of the hazards normally taken into account in calculating fire risk, but does provide an approximate indication of true risk. For more information on your home's fire risk, or for a more complete evaluation of your property, contact your local Department of Forestry office.
SECTION 7 – Evaluated By
Evaluator Name (Print)	Evaluator Signature	Date