Form FEMA Form 75-100 FEMA Form 75-100 NATIONAL FIRE DEPARTMENT CENSUS

http://www.usfa.dhs.gov/applications/census/

DEPARTMENT OF HOMELAND SECURITY O.M.B. No. 1660-0070

Expires

NATIONAL FIRE DEPARTMENT CENSUS

Fire Department Name: _________________________________________________________________

Fire Department Identification Number (FDID) if known: __ __ __ __ __

The FDID is a unique identifier assigned by the state for fire incident reporting purposes. If FDID is unknown, leave blank.

Fire Department Headquarters Address (physical location of the fire department)

Address Line 1: ________________________________________________________________________

Address Line 2: ________________________________________________________________________

City: _______________________________ State: __ __ Zip Code: __ __ __ __ __ - __ __ __ __

County: ____________________________

Fire Department Mailing Address (if different than headquarters address)

Address Line 1: ________________________________________________________________________

Address Line 2: ________________________________________________________________________

Post Office Box Number: ________________________________________________________________

City: _______________________________ State: __ __ Zip Code: __ __ __ __ __ - __ __ __ __

Number of Stations _________

Please indicate the total number of fire stations within your department.

Note: If your fire department is comprised of two or more independently incorporated fire companies; please list the names and addresses of those companies on the enclosed supplemental address sheet. An example of this would include a county fire department that is comprised of two or more independently incorporated fire companies.

Fire Department Headquarters Telephone Number: (__ __ __) __ __ __ - __ __ __ __

Fire Department Headquarters Fax Number: (__ __ __) __ __ __ - __ __ __ __

Fire Department Email Address: _____________________________

Please complete only if this is a department email address. Do not use personal email addresses.

Fire Department Web Address: _____________________________

If your fire department maintains a web site, please provide the web address (URL) above.

PAPERWORK BURDEN DISCLOSURE NOTICE

Public reporting burden for this information collection is 25 minutes per response.   Burden means the time, effort and financial resources expended by persons to generate, maintain, retain, disclose, or to provide information to us.  You may send comments regarding the burden estimate or any aspect of the collection, including suggestions for reducing the burden to: Information Collections Management, U.S. Department of Homeland Security, Emergency Preparedness and Response Directorate, Federal Emergency Management Agency, 500 C Street, SW, Washington, DC 20472, Paperwork Reduction Project (OMB Control Number 1660-0070).   You are not required to respond to this collection of information unless a valid OMB control number appears in the upper right corner of this form.  Note: Do not send your completed questionnaire to this address.

FEMA FORM 75-100, MAY 06 REPLACES ALL PREVIOUS EDITIONS

Organization Type

Select the choice that best describes your fire department:

 Local (includes career, combination, volunteer fire departments and fire districts.)

 State Government (includes state forest fire agencies and state institution fire departments)

 Regional/metropolitan transportation authority or airport fire department

 Federal Government - Executive branch agency fire department

 Federal Government - Department of Defense fire department

 Private or industrial fire brigade

 Contract fire department

 Other (please explain) ______________________________________________

Emergency Management

Emergency Management (EM):  integration and coordination of all-hazards mitigation,  prevention,  preparedness, response, and recovery activities within a community for all (or most) agencies such as fire, EMS, public works, public information, volunteer service, etc.

Is your fire department the primary agency responsible for community emergency management? 

 Yes

 No

 

If no, then what agency is the primary agency responsible for emergency management in your community?  ___________________________________________________

Population Protected __,__ __ __,__ __ __

Provide the total permanent resident population protected by your department and the source for the information provided.

 U.S. Census

 Estimate

 Other ______________________________

Area Protected __ __ , __ __ __ Square miles

Provide an estimate of the total primary response area in square miles protected by your department.

Number of active firefighting personnel

Counting all stations, how many active career, volunteer, and paid per call firefighting personnel does your department have? (Please indicate the number next to the category.)

____ Career

Indicate total number of full-time paid fire officers and firefighters within your department.

____ Volunteer

Indicate the total number of active firefighting volunteers within your department. A volunteer is defined as a member who receives no compensation for his or her services.

____ Paid per call

Indicate the total number of firefighters in the department who are not full-time paid firefighters but receive compensation for their participation.

Number of non firefighting support personnel

____ Non-firefighter volunteers

____ Civilian full-time and part-time employees

Specialized Services Provided

Some departments provide specialized services. As you read through the lists below, please check each of the specialized services your department provides.

 Wildfire/Urban-Wildland Interface

 Airport/Aviation

 Fireboat

 EMS Ambulance Transport

 EMS Non-Transport Response

 Basic Life Support (BLS, First Responder/EMT-Basic Level of Care)

 Advanced Life Support (ALS, EMT-Paramedic/EMT-Intermediate Level of Care)

 HAZMAT Team (Technician Level)

 Vehicle Extrication

 Technical/Specialized Rescue (Confined Space Rescue, Rope Rescue, Swiftwater Rescue, Dive Rescue, Building Collapse Rescue/Urban Search and Rescue, etc.)

 Fire Inspection/Code Enforcement

 Fire/Injury Prevention/Public Education

 Departmental (in-house) Training Academy

 Fire Investigation/Fire Cause Determination

 Sworn (Investigators have power of arrest)

 Non-Sworn

 Juvenile Firesetter Intervention Program

United States Fire Administration Programs

Is your fire department familiar with United States Fire Administration programs and publications?

 Yes

 No

If yes, How? (check all that apply)

 Web Site http://www.usfa.dhs.gov/

 Publications

 National Fire Academy Courses

 National Fire Incident Reporting System (NFIRS)

 Public Fire Education Programs

 Other __________________________________________

Survey Completed by:

Please provide contact information for the person completing this survey.

Name (Please Print) ____________________________________________

Telephone Number: (__ __ __) __ __ __ - __ __ __ __

Fax Number: (__ __ __) __ __ __ - __ __ __ __

Email Address: _____________________________

Supplemental Address Sheet

(Please make additional copies if necessary.)

Fire Company Name: _________________________________________________________________

Address Line 1: ________________________________________________________________________

Address Line 2: ________________________________________________________________________

City: _______________________________ State: __ __ Zip Code: __ __ __ __ __ - __ __ __ __

Fire Company Name: _________________________________________________________________

Address Line 1: ________________________________________________________________________

Address Line 2: ________________________________________________________________________

City: _______________________________ State: __ __ Zip Code: __ __ __ __ __ - __ __ __ __

Fire Company Name: _________________________________________________________________

Address Line 1: ________________________________________________________________________

Address Line 2: ________________________________________________________________________

City: _______________________________ State: __ __ Zip Code: __ __ __ __ __ - __ __ __ __

Fire Company Name: _________________________________________________________________

Address Line 1: ________________________________________________________________________

Address Line 2: ________________________________________________________________________

City: _______________________________ State: __ __ Zip Code: __ __ __ __ __ - __ __ __ __

Fire Company Name: _________________________________________________________________

Address Line 1: ________________________________________________________________________

Address Line 2: ________________________________________________________________________

City: _______________________________ State: __ __ Zip Code: __ __ __ __ __ - __ __ __ __