Home > Your Safety > Arson and Antisocial Behaviour > Threat of Arson and Domestic Abuse Form

Threat of Arson and Domestic Abuse Form 2026

This form has been designed to refer high risk domestic abuse victims, at risk of arson threats. By using this form we will action any request that come in, regardless of the day or time.

"*" indicates required fields

Referral Details

DD slash MM slash YYYY
Type of referral being made
This is where the referred data-subject is considered to present a legitimate risk (not speculative) to NYFRS staff visiting the property and NYFRS may need to consider additional measures to safeguard their staff. This can include but is not limited to physical violence, firearms, and organised crime.
All information recorded will be maintained in accordance with the Data Protection Act 2018. We have a duty to act on every referral you make to us. If the occupier has not given consent, please ensure you have, and understand, your legal basis for sharing the information.
Does the perpetrator also live at the above address?*
Are there any known associates who may pose a risk if present during a visit?
Has the occupier previously been a victim of arson or other fire related crime?
Are there any other households that may be at risk?
If yes, please complete any additional referral forms
Does the Home Fire Safety Visit need to be carried out as joint visit with either the referring agency or family?
If yes, please ensure that contact details for the agency point of contact or family are provided
Do any other agencies work with the person you are referring in?
Are there any other risk or environmental factors that NYFRS should be aware of before a visit is carried out?
For example an aggressive pet or unsanitary environment

Occupier details

Details of person requiring a visit

Name*
MM slash DD slash YYYY
Address*
Including area code if land line
This will help us decide on the best course of action

Pre visit assessment details

Property ownership type*

e.g. as result of a disability, language barrier

Pre-Visit Assessment

Does the property have working smoke alarms?*
Is there anyone living in the home aged 65 or over?
Do any of the rooms in the home resemble images 4-9 in terms of clutter? Please see clutter index rating for guidance
Are the properties exit routes obstructed or cluttered?
Does anyone living in the home have any of these disabilities or health conditions
Are any of the following relevant to someone in the household

How we use your information:

North Yorkshire Fire and Rescue Service (the Authority) as the data controller will process your information in line with relevant data protection laws. To find out more about how we will use the information you provide on this form and to deal with your enquiry, please view our Privacy Notice

 

 

Share: