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					                           Pre-survey Information Request
                                         for
                    Fire Department Features for Fire Suppression
                                Automatic Aid Fire Departments

NORTH CAROLINA DEPARTMENT OF INSURANCE is responsible for the certification and
rating of fire departments in North Carolina. An important part of the information the NORTH
CAROLINA DEPARTMENT OF INSURANCE, OFFICE OF STATE FIRE MARSHAL
provides to insurers is a community’s Public Protection Classification (NORTH CAROLINA
RESPONSE RATING SYSTEM) number. The NORTH CAROLINA RESPONSE RATING
SYSTEM program evaluates community fire suppression delivery systems according to a
uniform set of criterion, incorporating nationally recognized standards developed by the National
Fire Protection Association.


Following is a 5-page questionnaire. Please record as much of the information as possible on
these forms. For questions that are not applicable to your AA fire departments, please indicate
“Does not apply” or “DNA”.

Some questions indicate that an exhibit is necessary and imply the file name (e.g., “Exhibit 2A –
5 – Outside Aid Agreement”) that should be used. This nomenclature will assist OFFICE OF
STATE FIRE MARSHAL in their survey.

Certain questions may need multiple answers. For example, question 13 asks questions about
automatic aid departments and provides the space to record the data for a single automatic aid
fire department. Communities may receive automatic aid from multiple departments. To
accommodate the entry of multiple providers, this file has been provided. A separate file should
be created for each AA fire department to be considered in your grading.

Your cooperation in assembling this information prior to the OFFICE OF STATE FIRE
MARSHAL visit will greatly assist in expediting the survey as well as helping to ensure that
your community receives all of the credit to which it is entitled. Answers may need to be
changed if forms are updated from past inspection data. Be sure all information is current and up
to date for each time these forms are used.




     North Carolina
Office of State Fire Marshal                                                 Edition 6/17/07
   4


                  Survey of the Fire Department Features for Fire Suppression

Name of AA Fire Agency:                                                    Date of Information:

Apparatus and Equipment
 9. Show each existing pumper location, tools and equipment carried, hose carried, and test information.
    Use the “Apparatus and Equipment” form found in Appendix A. Note that the OFFICE OF STATE
    FIRE MARSHAL credits equivalencies to many of the equipment items. See the “Equipment
    Equivalencies List”


10. Are hose tests conducted in accordance with the applicable NFPA Standards?            Yes:       No:
    Please provide an exhibit to document the hose test information (Exhibit 2A – 10 – Hose Tests). For
    NC RRS purposes, the exhibit should indicate by section of hose the size, the dates tested, the service
    test pressure, length of time of test, and whether it passed or failed.


11. Are apparatus tests conducted in accordance with the applicable NFPA Standards?       Yes:      No:
    Please provide an exhibit to document the apparatus test information (Exhibit 2A –11 – Apparatus
    Tests). For OFFICE OF STATE FIRE MARSHAL the exhibit for pump tests should indicate at a
    minimum - apparatus number or designation; apparatus manufacturer, year of manufacture, and
    Vehicle Identification Number (VIN); pump rated capacity; dates (month, day and year)of tes; test
    capacity at 150psi, 200psi, and 250psi; and be signed. The exhibit for aerial device tests should
    indicate apparatus number or designation; apparatus manufacturer, year of manufacture, and Vehicle
    Identification Number (VIN); dates (month, day and year) of tests; non-destructive tests (every five
    years); and annual visual inspection, operational, load and water system tests.




        North Carolina
   Office of State Fire Marshal                  Page 1 of 5                                  Edition 6/17/07
4


Group the apparatus by station, and label the stations. Indicate each combination of planned responses to reported building fires by placing an X in
the appropriate column for each responding apparatus. Indicate under a new category (under “Area/Zone Responded To”) if the responses vary due
to location of fire (commercial, institution, residential, etc.), time of day, method of the receipt of the alarm, reported type of fire, etc.,

                                                   APPARATUS RESPONSE FORM

                                                                    Apparatus Responding From
                                                                              Station

     Area/Zone                                                 Engine (E) or Ladder/Service (L/S) Company
    Responded To




     North Carolina
Office of State Fire Marshal                               Appendix A1                                                         Edition 6/17/07
4


     Automatic Aid
13. For each fire department providing automatic aid, please provide the following information:
    a. For the automatic aid companies that are within 5-road miles of the outer boundary of the area to
        which the response is required, please indicate the type and average number of personnel
        responding over the previous 12 month period of time:
          Name of Fire Department providing automatic aid:
          Company Name/No.                              On duty:                                 Volunteer:
          Company Name/No.                              On duty:                                 Volunteer:
          Company Name/No.                              On duty:                                 Volunteer:
          Company Name/No.                              On duty:                                 Volunteer:
          Company Name/No.                              On duty:                                 Volunteer:
    b. Is the fire apparatus dispatched on the initial alarm to a reported structure fire?     Yes:     No:
    c. Does the responding apparatus meet the general criteria of NFPA Standard 1901, “Standard on
        Automotive Fire Apparatus” including emergency lights and siren and, for apparatus
        used to pump water, a permanently mounted pump?                                        Yes:     No:
    d. Did the responding paid or volunteer automatic aid fire fighters receive a minimum of 12
        hours of structural fire fighting training within the last year?                       Yes:     No:
    e. Is each automatic aid structure fire apparatus housed in a building that protects it from the
        weather?                                                                               Yes:     No:
     f. Indicate how the automatic aid company receives its dispatch from the requesting agency:
          Dispatch from requesting agency by: Radio:            Alpha-numeric pager:       Telephone:
    g. Does the automatic aid fire department respond to all of the structure fire alarms received
        from the requesting agency?             Yes:       No:
   h. Does the automatic aid fire department dispatch their companies to the requesting agency’s
        structure fires by running cards or the equivalent?               Yes:     No:
   i. Provide an exhibit to demonstrate the frequency and duration of inter-departmental training (Exhibit
        9A – 13 – Automatic Aid Training). For the last 12-months, indicate the companies involved; the
        subject of the training; the duration; type (e.g., hose evolutions, classroom, live fire, etc.); location;
        and date.
   j. Is there an inter-agency radio frequency capability that would permit communication
        between mobile apparatus?              Yes:       No:
        Is there an inter-agency radio frequency capability that would permit communication
        between portable radios?               Yes:       No:
   k. Is there a joint Communication/Dispatch Center that receives and dispatches all structure
        fire alarms?                           Yes:       No:
   l. For each automatic aid apparatus, show each existing apparatus location, tools and equipment
        carried, hose carried, and test information. Use the “Apparatus and Equipment” form found in
        Appendix A. Note that the OFFICE OF STATE FIRE MARSHAL credits equivalencies to many of
        the equipment items. See the “Equipment Equivalencies List” in Appendix A.




     North Carolina
Office of State Fire Marshal                          Appendix A2                                 Edition 6/17/07
4

    Personnel
    14. Please provide the total quantity and type of service for the positions indicated below:
           Position                                          Quantity/Type
           Chief              On-duty:               Volunteer:               Public Safety Officer:
           Deputy Chief       On-duty:               Volunteer:               Public Safety Officer:
           Assistant Chief On-duty:                  Volunteer:               Public Safety Officer:
           Battalion Chief On-duty:                  Volunteer:               Public Safety Officer:
           Captain            On-duty:               Volunteer:               Public Safety Officer:
           Lieutenant         On-duty:               Volunteer:               Public Safety Officer:
           Sergeant           On-duty:               Volunteer:               Public Safety Officer:
           Driver             On-duty:               Volunteer:               Public Safety Officer:
           Fire Fighter       On-duty:               Volunteer:               Public Safety Officer:
           Chief’s Aide       On-duty:               Volunteer:               Public Safety Officer:
           Non-fire Force On-duty:                   Volunteer:               Public Safety Officer:
                              On-duty:               Volunteer:               Public Safety Officer:
                              On-duty:               Volunteer:               Public Safety Officer:

         For additional positions, please record the information on an attached page (see Appendix A).


    15. Please provide the following existing (do not include vacant but budgeted for positions) company
        staffing

                                         On-Duty Membership                 Volunteer Membership
                           Fire      Company      Fire                  Company      Fire
            Company       Station    Officers   Fighters  Total         Officers   Fighters   Total




             TOTALS




     North Carolina
Office of State Fire Marshal                         Appendix A3                               Edition 6/17/07
4




    19. Please provide the following information for personnel that responded, on first alarm, to structural
        fire alarms within the jurisdiction during the previous 12 months, not to exceed 20 responses.
        Record, by company, the number that responded on each incident.
                                     V=VOLUNTEER, P=PAID ON DUTY
              Response Records                                   Company Name/Number
               Date     Time        Chief                                                           PV/Station
    Example   11/11/05     1321         1       4-P, 5-V        0       1-P, 2-V       3-V          2-P         4-V




                             Sum:

         Please provide the incident reports to document this information (Exhibit 2A – 19 – Personnel Fire Responses).
         For additional personnel, please record the information on an attached page (see Appendix A).




     North Carolina
Office of State Fire Marshal                               Appendix A4                                    Edition 6/17/07

				
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