Docstoc

1A

Document Sample
1A Powered By Docstoc
					                                       FIRE INCIDENT REPORTING FORM
1A                     MM     DD       YY
__________      V T  ____ ____ ________ ______
______________     ______
FDID         State     Incident Date      Station   Incident Number                                              Exposure
                        (See Short Form Reference Guide for Coding Information)
1B Location: ____ _______________________________________________________________
                                                          Street or Highway
   ____        ____________________________________________ ____                                 __________-
________
Apt/Suite/Room           City                                                 State               Zip Code


1C Incident Type                                                      1E Dates & Times                       Midnight is 0000
                                                                   Month         Day                Year             Hour        Min.
_________ _________________                               Alarm ______ ______ ____________
____________
                                              Arrival ______ ______ ____________
                      ____________
 1D Mutual Aid Given or Received          Controlled ______ ______ ____________
____________
□ Mutual aid received               Last Unit Cleared ______ ______ ____________
____________
□ Automatic aid received
□ Mutual aid given     ______ 1F Actions Taken                      1G1 Resources (number)
□ Automatic aid given Their State ____ _________________                   Apparatus   Personnel
□ Other aid given                  Primary Action 1                  Suppression ______ ______
□ None                             ____ _________________ EMS                      ______
      ______                                                       Additional Action Taken 2 (Optional)            Other
______ ______
                                          ____ _________________
                                          Additional Action Taken 3 (Optional)


1G2 Estimated Dollar Loss & Value              1H1 Casualties: Injuries Fatalities 1H3 Hazards Materials
Property: $ _________                             Fire Service: ____   ____             ____
Contents: $ _________                             Civilian      ____   ____
Pre-incident Value                                None
Property: $ _________
Contents: $ _________
                                                                2D Ignition   2E1 Cause of Ignition
1J Property Use: ______ Units (Multi-family) ________        ____    1□ Intentional
                                                                                       Unintentional
                                                                                 Area of Origin              2□
                                    Acres Burned ______ , ______  ____         3□ Failure of
equipment                                                                      Heat Source         4□ Act of
nature
                                                                                  ____                 5□ Cause under investigation
2E3 ____ Estimated age of Person Involved                                              Item first ignited      U□ Cause
undetermined
□ Age was a factor         □ Male     □ Female                                                                    after investigation

2F1 Equipment Involved              2F2 Equipment Power 2G Fire Suppression                        2H2 Mobile Property involved
       in the Ignition                                                 Factor                                in the Ignition
______ ________________                    ____                     ____ ________________ ____
Mobile Property Type                                                                                Fire Suppression Factor 1


Brand     ________________                                        ____ ________________ ____ Mobile
Property Make                                                                             Fire Suppression Factor 2


Model    ________________                                         ____ ________________
________________________
                                                                     Fire Suppression Factor 3      Mobile Property Model
Serial          ________________                                                                       Year ________

Year     ________
______________________________________
                                 VIN Number


Page 2 – Fire Incident Reporting Short Form
3I Structure Type                     3I2 Building Status        3I3 Building Height 3I4 Main Floor Size
1□ Enclosed building                   1□ Under Construction          do not count the roof   __, ______,
______
2□ Portable/mobile structure           2□ Occupied & Operating        ______                      OR
3□ Open structure                      3□ Idle, not routinely used    total number of stories
4□ Air supported structure             4□ Under major renovation      at or above grade       __, ______ BY
______
5□ Tent                                   5□ Vacant and secured            ____                                    Length in feet
width in feet
6□ Open Platform (e.g. piers)             6□ Vacant and unsecured          Total number of stories below grade
7□ Underground structure (work areas)     7□ Being demolished
8□ Connective structure (e.g. fences)     0□ Other
0□ Other type of structure                U□ Undetermined
                                      * * * * * * ** * * * * * * * * * * * * * * * * * * * * * * * * * * * ***
3J1 Fire Origin                  *     3L2 Detector Type                      3L4 Detector Operation
______         □ below grade  *     1□ Smoke                               1□ Fire too small to activate
(Story of fire origin)            *     2□ Heat                                2□ Operated
3J2 Fire Spread                  *     3□ Combination smoke-heat              3□ Failed to operate
2□ Confined to room of origin     *     4□ Sprinkler, water flow detection     U□ Undetermined
3□ Confined to floor of origin    *     5□ More than 1 type present
4□ Confined to building of origin *     0□ Other ___________________           3L5 Detector Effectiveness
5□ Beyond building of origin      *     U□ Undetermined                        1□ Alerted, occupants responded
****************** *                                                           2□ Occupants failed to respond
3L1 Presence of Detectors              3L3 Detector Power Supply              3□ There were no occupants
N□ None present                         1□ Battery Only                        4□ Failed to alert occupants
1□ Present                              2□ Hardwire                            U□ Undetermined
********************                    3□ Plug in
3M1 Presence of Automatic         *    4□ Hardwire with battery               3L6 Detector Failure Reason
   Extinguishing System            *    5□ Plug in with battery                1□ Power failure/disconnect/off
N□ None             1□ Present     *    6□ Mechanical                          2□ Improper installation or place
                                   *    7□ Multiple detector & power supplies 3□ Defective
3M2 Type of Automatic              *    0□ Other ___________________           4□ Lack of maintenance/cleaning
Extinguishing System               * * U□ Undetermined * * * * * * * * * * * * 5□ Battery missing or disconnected
1□ Wet pipe sprinkler                   3M4 Number of Sprinkler Heads * 6□ Battery discharged/dead
2□ Dry Pipe                             (if system operated)                 * 0□ Other ___________________
3□ Other sprinkler system               ______                                   * U□ Undetermined
4□ Cry chemical system                 (Number of sprinkler heads operating) * * * * * * * * * * * * * * * * * * * * *                 * *
5□ Foam system
6□ Halogen type system                  3M5 Automatic Extinguishing System Failure Reason
7□ Carbon dioxide                       1□ System shut off
0□ Other special hazard system          2□ Not enough agent discharged
U□ Undetermined                      3□ Agent discharged but did not reach fire        1SL1 Special Studies
                                     4□ Wrong type of system
3M3 Automatic Extinguishing          5□ Fire not in area protected                     __________
__________
System Operation                     6□ System components damaged                      Special         Special
1□ Operated & effective              7□ Lack of maintenance                            Study ID #      Study Value
2□ Operated & not effective          8□ Manual intervention
3□ Fire too small to activate        0□ Other ________________________                  __________
__________
4□ Failed to operate                 U□ Undetermined                                    Special        Special
0□ Other                                                                                Study ID #     Study Value
U Undetermined
Remarks:



Authorization:
____________ __________________________ _________ _________ ______ ______
____________
Officer in Charge ID     Signature                      Position/rank   Assignment   Month    Day          Year


____________ __________________________ _________ _________ ______ ______
____________
Member Making Report     Signature                      Position/rank   Assignment   Month    Day          Year

				
DOCUMENT INFO