Introduction to NFRIS Distance Learning (Training)

National Fire Incident Reporting System (NFIRS) Version 5.0

NFIRS Module 6 - EMS

Introduction to NFRIS Distance Learning (Training)

OMB: 1660-0069

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 1660-0069 can be found here:

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NFIRS 5.0 Self-Study Program

Emergency Medical
Services (EMS) Module:
NFIRS-6

Objectives
After completing the EMS Module the student will be able to:
1. Identify the different modules that are used to record casualties.
2. Understand the need for the various modules and which module to
use in various circumstances.
3. Demonstrate how to complete the EMS Module, given hypothetical
narrative reports.

6-1

Table of Contents
Pretest #6 - Emergency Medical Services (EMS) Module. . . . . . . . . . . . . . . . . . . . . . . . . . . . 6-3
Using the EMS Module. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6-4
Section A: FDID, State, Incident Number, Incident. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6-5
Section B: Number of Patients and Patient Number. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6-5
Section C: Date/Time. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6-5
Section D: Provider Impression/Assessment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6-6
Section E: Age or Date of Birth, Gender . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6-6
Section F: Race, Ethnicity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6-7
Section G: Human Factors Contributing to Injury and Other Factors. . . . . . . . . . . . . . . . . . . 6-7
Section H: Body Site of Injury, Injury Type, and Cause of Injury/Illness. . . . . . . . . . . . . . . . . 6-8
Section I: Procedures Used. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6-9
Section J: Safety Equipment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6-9
Section K: Cardiac Arrest. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6-10
Section L: Initial Level of Provider and Highest Level of Care Provided on Scene. . . . . . . . . 6-10
Section M: Patient Status. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6-11
Section N: Disposition. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6-11
SUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6-12
EXAMPLE: Injured Person. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6-13
EXERCISE SCENARIO 6.1: Unconscious Person. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6-15
EXERCISE SCENARIO 6-2: MVA on I-95. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6-18
Emergency Medical Services (EMS) Module Test. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6-23

NFIRS 5.0 Self-Study Program

Pretest #6 - Emergency Medical Services (EMS) Module
1. A Basic Module must be completed if the EMS Module is completed.

(a) True.

(b) False.

2. EMS-type activities are a significant portion of a fire department’s operational workload.

(a) True.

(b) False.

3. The EMS Module is a required NFIRS Module.

(a) True.

(b) False.

4. The purpose of the EMS Module is to gather basic data as they relate to the provision of emergency medical care by local fire service units.

(a) True.

(b) False.

5. The EMS Module can be used instead of the Fire Service Casualty Module to document a firefighter injury.

(a) True.

(b) False.

6-3

NFIRS 5.0 Self-Study Program

Using the EMS Module

n its infancy, fire department activity reporting was limited to fires only - at least on a national
level. Little recognition was given to the “other” activities that fire departments were performing on a daily basis. As fire department management became more responsive to the budgetary
concerns and restrictions of fiscal policy, the need to justify all activities and expenditures grew.
Many local fire departments began to collect data on their own, using the NFIRS program to
attempt to gather management information concerning all of those other activities and stretching
the program in directions that were never anticipated. Recognizing that EMS-type activities are a
significant portion (well over 50 percent) of a fire department’s operational workload, the EMS
Module was created in 1996.
The EMS Module is an optional module. It should be used when that option has been chosen by
your State or local authorities. The EMS Module is not intended to replace or otherwise interfere with
State or local EMS patient care reporting requirements, nor is it intended to be a comprehensive EMS
patient care report. Instead, the data elements in this module should be viewed as “core elements”
around which a complete patient care report can be built.
The purpose of the EMS Module is to gather basic data as they relate to the provision of emergency
medical care by local fire service units. It is intended to encompass both responding fire suppression
units and fire department EMS units.
Use the optional EMS Module to report each medical incident that a department responds to. This
module is completed only if the fire department provides emergency medical service. If an independent provider performs EMS, do not use this module.
NOTE: Data on fire services injuries or deaths are recorded on the Fire Service Casualty Module.The EMS Module does not replace
the Civilian Fire Casualty Module in cases where a civilian injury or death results from a fire incident.
Whenever specific 300 series Incident Types (e.g., 311, 322, 371, etc.) are entered on the Basic
Module, Section C, you also may complete the EMS Module. It also may be completed for injuries
treated in certain other incident types (consult the CRG for specifics).
One EMS Module should be completed for each patient, and the number of modules submitted for
an incident should match the Number of Patients entered in Block B of the paper form.

Section A: FDID, State, Incident Number, Incident
MM

FDID

Incident Date

State

Number of Patients

YYYY

Patient Number

NFIRS–6

Delete
Station

Incident Number

Date/Time

EMS

Change

Exposure
Month

Day

Inhalation injury
Obvious death
OD/poisoning
Pregnancy/OB
Respiratory arrest
Respiratory distress
Seizure

35
36
37
38
00

Year

Hour/Min

C Module is drawn
B information in Section A of the EMS
Time Arrived
at Patient
The
from
Section A of the Basic Module. Use
Check if same date
as
Alarm
date
the
inform
thefor each
Basic
Module to help you supply the requested
If you are using an autoTime of Patient information.
Transfer
Usedata
a separate
patient
mated
system
the
data
need
to
be
entered
only
once,
then
they
will
be
transferred
automatically
into
None/no patient
or refused treatment
D Provider Impression/Assessment Check one box only
other
modules
that use the
data.Chest pain
34
18
26
Hypovolemia
Sexual assault
10
Abdominal pain
11
12
13
14
15
16
17

Airway obstruction
Allergic reaction
Altered LOC
Behavioral/psych
Burns
Cardiac arrest
Cardiac dysrhythmia
Age or Date of Birth

19
20
21
22
23
24
25

Diabetic symptom
Do not resuscitate
Electrocution
General illness
Hemorrhaging/bleeding
Hyperthermia
Hypothermia

6-4

Race
1

27
28
29
30
31
32
33

White

Human Factors
Contributing to Injury

None

Sting/bite
Stroke/CVA
Syncope
Trauma
Other

Other
Factors

None

NFIRS 5.0 Self-Study Program

Section B: Number
of Patients and Patient Number
A
MM

FDID

Patient Number

Day

MM
FDID

Time of Patient Transfer

None/no patien

Check one box only

Station

Patient Number

Incident
Number
Age
or

Date of BirthExposure
F1
Month

Date/Time

Check if same date
as Alarm date

Provider Impression/Assessment

21
22
23
24
25

Altered LOC
Behavioral/psych
Burns
Cardiac arrest
Cardiac dysrhythmia

Electrocution
General illness
Hemorrhaging/bleeding
Hyperthermia
Hypothermia
NFIRS–6
Delete

Section C: Date/Time

YYYY

Incident Date

State

Number of Patients

13
14
15
16
17

Months
(for infants)
Time Arrived at
Patient

Age

OR Transfer
Time of Patient

Check one box only

Race

Time Arrived at Patient

29
30
31
32
33

1Day
2
3
4
5

WhiteYear
Hour/Min
Black, African American
Am. Indian, Alaska Native
Asian
Native Hawaiian, Other
Pacific Islander
None/no
patientmultiracial
or refused treatment
0
Other,
U
Undetermined

34
35
36
37
38
00

OD/poisoning
Pregnancy/OB
Respiratory arrest
Respiratory distress
Seizure

EMS

Change

Human Factors
Contributing to Injury

S
S
S
S
T
O

None

I
i

Check all applicable boxes

Asleep
Unconscious
Possibly impaired by alcohol
Possibly impaired by drug
Possibly mentally disabled
Physically disabled
Physically restrained
Unattended person

1
2
3
4
5
6
7
8

Month
Day
Year
Use the 18
first line
to record Time Arrived
at Patient.
This is the
date and
time when emergency person34
Hypovolemia
26
Sexual assault
Chest pain
Abdominal pain
nel get 19
to the Diabetic
same location
This injury
data element
35 is important
Inhalation
27 patient.
Sting/bite in situations where there
symptom as the
Airway obstruction
E282 Gender
F2 1Ethnicity Stroke/CVA
Obvious death
Do not resuscitate
Allergic reaction
Hispanic or unit
Latino arrives on the scene and
may be 20
a significant
amount of time
between
the time an36
emergency
37
OD/poisoning
21
291
Electrocution
Female
Altered LOC
2
Male
2
NonSyncope
Hispanic or Latino
the time22that direct
is made
the patient.
38
Pregnancy/OB
30 with
Trauma
General contact
illness
Behavioral/psych

Burns
Cardiac arrest
Cardiac dysrhythmia

Examples:
24

Age or Date of Birth

Months (for infants)

OR
Day

Year

Respiratory
arrest
Hemorrhaging/bleeding 31 Body
Site of Injury
H
to five body sites distress
321 List upRespiratory
Hyperthermia
Seizure
33
Hypothermia

Other

Gender

1
2
3

Injury Type
List one injury type for each body site listed under H1

EMS personnel were prevented from approaching a patient because of a fire, criminal activity, or
Human Factors
None
None
F1 Race
G1 Contributing to Injury
G2 Other
other
adverse
conditions.
Factors
1
White
2

Black, African American

4
5

Asian
Native Hawaiian, Other
Pacific Islander
Other, multiracial
Undetermined

If an illness, not an
3
Am. Indian,
Native an upper floor of a highrise building in order to gain access to a patient.
Responders
needAlaska
to reach
injury, skip G2 and
Asleep
1
Check all applicable boxes

Unconscious

go to H3

Enter the Time of Patient Transfer 23on Procedures
the
second
line.by
This
documents the date
and time that
patient
Used
Check
all applicable boxes
Possibly impaired
alcohol
No treatment
I
None K
J Safety
0
Equipment
Possibly
impairedto
by another
drug 14 care
care wasUtransferred from fire department
personnel
provider,
or the time transporta1 Intubation
Accidental
Airway
insertion
014
(EGTA)
Possibly mentally
5
Self-inflicted
Anti-shock
trousers disabled 15 2 Intubation
Used or deployed by patient.
(ET)
tion began to an emergency care02facility.
1
Check all applicable boxes.
Physically disabled
6

Inflicted,
not self
16 3 IO/IV
Assist ventilation
03
therapy
Physically
restrained
1
17
Hispanic or Latino
Bleeding
control
047
Medications therapy
Unattended
person
Female
1
Male 2
2
Non Hispanic or Latino
18
Burn
care
058
Oxygen therapy
19
Cardiac
pacing
06
OB care/delivery
Cause of
MM
DD TypeYYYY
Body Site of Injury
Injury
Cardioversion (defib) manual 20
instructions
HPrearrival
3 Illness/Injury
H1 List up to five body sites A
H2 List one 07
injury type for each body site listed under H1
21
Chest/abdominal
thrust
08
Restrain
patient
Incident
Date
FDID
Station
Incident
Number
Exposure
State
22
CPR
09
Spinal immobilization
23
Month extremities
Day
Year
Cricothyroidotomy
10
Splinted
Number of Patients
Date/Time
Patient Number
Cause of illness/injury
CDefibrillation by AED
B
11
Time Arrived at24
Patient Suction/aspirate
Check
date
EKGif same
monitoring
12
Other
00
as Alarm date
Time of Patient Transfer
Use a separate form for each patient
Extrication
13

Exposure
Month

Date/Time

Check if same date
as Alarm date

Provider Impression/Assessment

Incident Number

Record the total number of patients in the incident on the18first line
of Section B. Remember
that you
26
Hypovolemia
Chest pain
10
Abdominal pain
need to fill out a separate form for11each patient.
Enter
a
number
that
identifies
each
individual
patient
Inhalation
injury
19
27
Diabetic symptom
Airway obstruction
20
28
Obvious
death
Do
not
resuscitate
12
Allergic
reaction
on line two. Assign patient numbers starting with 001.

nth

Station

Use a separate form for each patient

se a separate form for each patient

0
1
2
3
4
5
6
7

YYYY

Incident Date

State

Number of Patients

Ethnicity

Pr
1
2

NFIRS–6
4Delete Helmet
EMS clothing
5Change Protective
6
Flotation device
Hour/Min
0
Other
U
Undetermined

Initial A

Section D: Provider Impression/Assessment

6-5

Chec

If pre-ar

1
Safety/seat
Subtracting the Arrival at Patient time from the Transfer time provides an accurate reading
of thebelts
2
Child safety seat
actual time spent with the patient.
3
Airbag

one box only
None/no patient or refused treatment
D Provider Impression/Assessment CheckInitial
Patient Status
Highest Level of Care
Level of
None M
L
1
L
2
Procedures Used 10 CheckAbdominal
all applicable boxes
Cardiac
Arrest
Safety
Provided
On Scene 34
No
18 treatment
26
Hypovolemia
Sexual
assault
ChestProvider
pain
pain
None
K
J Equipment
1
Improved
Check
all applicable boxes35
Inhalation
injury
Sting/bite
symptom
Airway
1
First Responder 27
14 obstruction
Airway insertion 11
Intubation 19
(EGTA) Diabetic
2
Remained
same
1
First Responder 36
28
Obvious death
Stroke/CVA
Do2 not resuscitate
12
Allergic
EMT-B
15 reaction
Anti-shock trousers
Used or(Basic)
deployed by patient.
Intubation 20
(ET)
Pre-arrival
arrest?
3
Worsened
1
2
EMT-B
(Basic)
Check all applicable boxes.
37
21
29
OD/poisoning
Syncope
Electrocution
Altered
3
EMT-I
(Intermediate)
16 LOC IO/IV therapy
Assist ventilation 13
3
IfEMT-I
pre-arrival
arrest, was it:
(Intermediate)
Check if:
38
22 therapy
30
Pregnancy/OB
Trauma
General
Behavioral/psych
4 1 illness
EMT-P
(Paramedic)
17
Bleeding control 14
Medications
Safety/seat belts 4
EMT-PWitnessed?
(Paramedic)
1
1
00
Pulse on transfer
23
31
Respiratory
arrest
Other
Hemorrhaging/bleeding
15
Burns
0
Other
provider
18
Burn care
Oxygen therapy
2
Child safety seat 0
Other provider
2
No pulse on transfer
Cardiac
24
32
Respiratory
distress CPR?
Hyperthermia
Bystander
N 3 No Training
2
19 arrest
Cardiac pacing 16
OB care/delivery
Airbag
Cardiac
33
Seizure
Hypothermia
17 manual
20 dysrhythmia
Cardioversion (defib)
Prearrival 25
instructions
4
Helmet
Post-arrival arrest?
2
21
Chest/abdominal thrust
Restrain
patient
5
Protective
clothing
Human Factors
Age or Date of Birth
Race
None
None
22
CPR
E1
1
G1 Contributing
G2 Other
Initial Arrest
Rhythm
SpinalFimmobilization
6
Flotation device
to Injury
Factors
1
White
23
Cricothyroidotomy
Splinted extremities
0
Other
2
Black, African American
Check all applicable
1 boxes V-Fib/V-Tach
If an illness, not an
Months
24 (for infants)
Defibrillation by AED
Suction/aspirate
3
Am. Indian,
Native
U Alaska
Undetermined
injury, skip G2 and
0
Other
Asleep
Age
1
4
Asian
EKG monitoring
Other
00
OR
go to H3
5
Native Hawaiian, Other
U
Undetermined
Unconscious
2
Extrication
Pacific Islander
Possibly impaired by alcohol
3
0
Other, multiracial
Possibly
drug
4
Month
Accidental
Day Highest
Year Level of Care
Initial Level of
EMS impaired by
Undetermined
Not transported 1
M Patient Status
1
L
2 Provided On Scene U None
NPossibly
mentally disabled
5
2
Provider
Disposition
Self-inflicted
1
Improved

Car

1
0
U

N
1
2
3
4
0

V
O
U

EMS
Dispositio

FD tr
NonNonNonOthe

NFIRS 5.0 Self-Study Program

Record the single clinical assessment that most influenced the responder’s actions by marking one
DD
YYYY
of the coded boxes provided. If more than one choice applies to MM
the patient,
indicate the single most
A
Incident
Date management. The
Station box Incident
Number
important clinical assessment that influencedFDIDthe plan ofStatetherapy
and
marked
should identify the actual assessment. This could
be different from the original complaint that the
B Number of Patients Patient Number C Date/Time
Time Arrived at Patient
unit responded to.
Check if same date
Use a separate form for each patient

as Alarm date
YYYY

Exposure
Month

Time of Patient Transfer

A
The assessment recorded on the form should
provide the information
needed to determine
whether
Incident Date
FDID
Station
Incident Number
Exposure
State
Check one box only
Non
Provider
Impression/Assessment
the treatments or medications providedDmatched the protocols related to the clinical impression at
Month
3D
18 Number
26
Hypovolemia
Chest painDate/Time
10
Abdominal
pain Patient
of Patients
the time of treatment.
Csymptom
B11 Number
3
Time Arrived
at Patient
Inhalation
injury
19
27
Diabetic
Airway obstruction
Check if same date

3
Obvious death
28
Time of Patient Transfer
3
29
OD/poisoning
Pregnancy/OB
30
Non3
0
Respiratory arrest
31
3
26
Hypovolemia
32
Respiratory distress
3
Inhalation
27
33
Seizure injury
3
Obvious death
28
3
Human
Factors
29
OD/poisoning
N
G1 Contributing
3
to Injury
Pregnancy/OB
30
0
Respiratory
arrest
31Check all applicable
boxes
Respiratory
distress
32
Asleep
1
33
Seizure
Unconscious
2
Pacific Islander
Possibly
impaired by alco
3
Human Factors
Age or Date of Birth
N
multiracial
E
1
F1 0URaceOther,
G
Possibly impaired
4 1 Contributing
Month
Day
Year
to Injuryby drug
Undetermined
1
White
MM
DD
YYYY
NFIRS–6
Possibly
mentally
disable
5
Delete
2
Black, African American
Check all applicable boxes
Months (for infants)
A
EMS
Physically
disabled
3Ethnicity
Am. Indian, Alaska Native
6
Gender
Change
Incident
Date
FDID
Station
Incident
Number
Exposure
State
E
F2 41 Asian
Asleep
Age2
17
Physically restrained
Hispanic or Latino
OR
1
5
Native Hawaiian, Other
Unconscious
28
Unattended
person
Month
Day
Year
Hour/Min
Female
2
1
Male
2
Non Hispanic
Number of Patients
Date/Time
Patient Number
Pacific
Islander or Latino
Possibly impaired by alco
3
C
B
MM
DD
YYYY
Arrived
at Patient
0 Time
Other,
multiracial
NFIRS–6
Delete
Possibly
impaired by drug
4
Check if same date
Month
Day Site Year
U
Undetermined
Body
of
Injury
Injury Type
A
EMS
as Alarm date
Change
H1DateList up to five body sites
H2 Exposure
Incident
Time
ofNumber
Patient Transfer
Station
Use aFDID
separate form for each
patient
Incident
5 type for Possibly
State
List one injury
each body sitementally
listed under H1disable
Physically
disabled
6
Ethnicity
Check one box only
patient
treatment
Month None/no
Day
Year or refused
Hour/Min
E2 Gender
D Provider Impression/Assessment
Date/TimeF2 1
Physically restrained
7
Hispanic or Latino
B Number of Patients Patient Number C Female
Time Arrived at Patient
Unattended
person
2
8
1
Male
34
226
NonHypovolemia
Hispanic or Latino
18
Sexual assault
Chest pain
10
Abdominal pain
Check if same date
as Alarm date
35
19
Inhalation
injury
27
Sting/bite
Diabetic
symptom
11 a separate
Airway
Time of Patient
Transfer
Use
form forobstruction
each patient
Injury
36
Obvious death Injury Type
20 Body
28
Stroke/CVA
DoSite
notof
resuscitate
12
Allergic reaction
H211 List upElectrocution
H2 List oneNone/no
Check
only
or refused
treatment
injury
for each body
site listed under
H1
Impression/Assessment
to five one
bodybox
sites
D13 Provider
37type patient
OD/poisoning
29
Syncope
Altered
LOC
38
22
Pregnancy/OB
30
Traumaassault
General
illness
14
Behavioral/psych
34
Hypovolemia
18
26
Sexual
Chest
pain
10
Abdominal
pain
00
23 Procedures
31
Respiratory
arrest
Other
Hemorrhaging/bleeding
15
Burns obstruction
Used
Check all
applicable boxes
Safety
No treatment35
19
Inhalation
injury
27
Sting/bite
Diabetic
symptom
11
Airway
I
None
J
Cardiac reaction
arrest
Respiratory
distress
24
32
Hyperthermia
16
Equipment
36
Obvious
death
20
28
Stroke/CVA
Do
not
resuscitate
12
Allergic
14
Airway
insertion
01
Intubation (EGTA)
CardiacLOC
dysrhythmia 21
Seizure
25
33
Hypothermia
17
37
29
Syncope
Electrocution
13
Altered
15 OD/poisoning
Anti-shock
trousers
Used
or deployed by patient.
02
Intubation (ET)
Check all applicable boxes.
38
22
Pregnancy/OB
30
Trauma
General
illness
14
Behavioral/psych
16
Assist
ventilation
03 Race
IO/IV
therapy
Human
Factors
Age or Date of Birth
None
Other
None
23
31G17
Respiratory
E
F1 04
1 Contributing
Hemorrhaging/bleeding
151
Burns
Bleeding
control
Medications
therapy 00 1 G2Other
toarrest
Injury
Safety/seat
Factors belts
1
White
Cardiac arrest
24
32 18 Respiratory
distress
Hyperthermia
16
Burn
care
05
Oxygen
therapy
2
Child
safety seat
Black, AfricanUsed
American Check all applicable
No treatment
Check boxes
boxes
If an illness,
not an
Months
(for infants)
I23 Procedures
None
Cardiac
dysrhythmia
25
Seizure
33 19 all applicable
J3 Safety
Hypothermia
17
Am.
Indian,
Alaska Native
Cardiac
pacing
06
OB care/delivery
Airbag
Equipment
injury,
skip G2 and
Asleep
14
Airway
insertion
Age
1 20
4
Asian
01
Intubation
(EGTA)
Cardioversion
(defib)
manual
07
Prearrival instructions 4
Helmet
OR
go tobyHpatient.
3
Human
Factors (ET)
5RaceNative
Hawaiian,
Other
None
Unconscious
Anti-shock
trousers
2 15
UsedOther
or deployed
None
Intubation
Chest/abdominal
thrust
08
Restrain
patient
E1 Age or Date of Birth F1 02
G
121Contributing
5 G2Check
Protective
all applicableclothing
boxes.
Pacific Islander
to
Injury
Factors
Possibly
impaired
by
alcohol
16
Assist
ventilation
3
03
IO/IV
therapy
10
White
22
CPR multiracial
09
Spinal
immobilization 6
Other,
Flotation device
2
Black,
African
American
Possibly
by drug 1
Bleeding
control
4 17
Check
1If
boxesimpaired
Month
04
Day
Year(for infants)
Medications
therapy
an Accidental
illness,belts
not an
Undetermined
Safety/seat
23all applicable
Cricothyroidotomy
Months
10
Splinted
extremities
0
3U Am.
Indian, Alaska Native
Other
Possibly
mentally
disabled
18
Burn
care
5
2
Self-inflicted
05
Oxygen
therapy
injury,
skip
G
2 and
2
Child
safety
seat
Age
1 24 Asleep
Defibrillation by AED
4
Asian
11
Suction/aspirate
U
Undetermined
OR
Physically
disabled
Cardiac
pacingOther
3Airbag
go to H3 not self
Inflicted,
OB
care/delivery
5 Ethnicity
Native
3
26 19
EKG Hawaiian,
monitoring
12
Other
00 Unconscious
E2 Gender
F206
Islander
Physically
restrained
Cardioversion
(defib) manual37 20 Possibly
07
Prearrival
instructions
1 Pacific
Hispanic
or Latino
impaired
by alcohol4
Helmet
Extrication
1
13
0
Other,
multiracial
Unattended
person
21
Female
Chest/abdominal
thrust
2
8
1
Male
08
2
Non
Hispanic
or
Latino
Restrain
patient
Possibly
impaired
by drug 5
clothing
4
1 Protective
Month
Accidental
Day
Year
U
Undetermined
CPRLevel of
09 Initial
Spinal
immobilization
Status
Highest
Level
of mentally
Care
6Patient
disabled
Flotation
device
5 22 Possibly
2
Self-inflicted
None
M
L1 Provider
L2 Type
Cause of
N
Cricothyroidotomy Injury
Body Site of Injury
10
Provided
On
Scene
Splinted
extremities
0
disabled
6 23 Physically
3 Other
not self
H3Inflicted,
H
2 List one injury
1
Improved
Illness/Injury
type
for each body site listed under H1
EH21 Gender
F2 1111Ethnicity
List up to five body sites
24
Defibrillation
by
AED
Suction/aspirate
U
Physically restrained
Undetermined
7
First Responder
Hispanic
or Latino
1
2
Remained same
1
First Responder
EKG
monitoring
12
Other person
Female
8 00 Unattended
1
Male 2
22
EMT-B
(Basic)
Non
Hispanic
or Latino
2
3
Worsened
2
EMT-B
(Basic)
Extrication
13
3
EMT-I (Intermediate) 3
3
EMT-I (Intermediate)
Cause of illness/injury
Check if:
Cause of
Body Site of Injury
Type
4
EMT-P (Paramedic) Injury
4
4
EMT-P
(Paramedic)
H
3
Highest
Level
of listed
Care
H1 List up to five body sites
H2 List one injury
Level
of
1 Patient
Illness/Injury
type for each
body site
under H1None M
PulseStatus
on transfer
Other
provider
L01 Initial
L02 Provided
0
N
OtherOn
provider
Scene
Provider
2
No pulse on transfer
N
No Training
1
Improved
1
First Responder
1
2
Remained same
1
First Responder
2
EMT-B (Basic)
Cause of illness/injury
2
3
Worsened
2
EMT-B (Basic)
Check3all applicable
boxes (Intermediate)
Cardiac Arrest
EMT-I
No treatment
3
I Procedures Used
NoneCheck
K
3
(Intermediate)
JEMT-ISafety
if:
Equipment
4
(Paramedic)
Check all applicable boxes
4
14EMT-PIntubation
Airway insertion
01
4
(EGTA)
EMT-P (Paramedic)
1
Pulse on transfer
0
0
15Other provider
Anti-shock trousers
or deployed by patient.
02
Intubation (ET) 0
OtherUsed
provider
Pre-arrival
arrest?
1
2
No pulse on transfer
Check all applicable boxes.
N
16No Training
Assist ventilation
03
IO/IV therapy
If pre-arrival arrest, was it:
Used
Check all applicable
17 boxes Medications
Bleeding control
Safety
No treatment
04
therapy
1
Safety/seat belts None K Cardiac Arrest
I Procedures
J
1 Check Witnessed?
Equipment
18
Burn care
all applicable boxes
05
Oxygen therapy
2
14
Child safety seat
Airway
insertion
01
Intubation
(EGTA)
Bystander CPR?
2
19
Cardiac
pacing
06
OB
care/delivery
3
15
Airbag
Anti-shock trousers
Used
or deployed by patient.
02
Intubation (ET)
Pre-arrival
arrest?
1
Check all applicable boxes.
20
Do not as
resuscitate
12
Allergic reaction
Alarm date
Use a separate form for each patient
21
Electrocution
13
Altered LOC
22
General
illness
Check one box
only
Behavioral/psych
Impression/Assessment
D14 Provider
23
Hemorrhaging/bleeding
15
Burns
18
Chest
pain
10
Abdominal
pain
Cardiac arrest
24
Hyperthermia
16
19
Diabetic
symptom
11
Airway
obstruction
Cardiac
dysrhythmia
25
Hypothermia
17
20
Do not resuscitate
12
Allergic reaction
Age
or Date
of Birth
Race Electrocution
Altered
LOC
E13
1
F1 21
22
General illness
14
Behavioral/psych
1
White
23
Hemorrhaging/bleeding
2
Black,
African American
15
Burns
Months (for infants)
3
Am.Hyperthermia
Indian, Alaska Native
Cardiac arrest
24
16
Age
4
Asian
Cardiac
Hypothermia
OR dysrhythmia 25
17
5
Native
Hawaiian, Other

Section E: Age or Date of Birth, Gender

Either enter the patient’s age or date of birth in Block E . You can record an infant’s age by marking
the Months box.

Record the patient’s gender by marking the appropriate box.

Section F: Race, Ethnicity

Mark the box that in Block F to record the patient’s race, if known.

F2 identifies the ethnicity of the patient. Ethnicity is an ethnic classification or affiliation. Currently
Hispanic is the only U.S. Census Bureau classification. Hispanic is not considered a race because a
person can be black and Hispanic, white and Hispanic, etc.

6-6

A
B

FDID

YYYY

Incident Date

State

Number of Patients

Station

Patient Number

NFIRS 5.0 Self-StudyMonth
ProgramDay

Date/Time

EMS

Change

Exposure

Incident Number

Year

Hour/Min

Time Arrived at Patient

Check if same date
as Alarm date

Use a separate form for each patient

NFIRS–6

Delete

Time of Patient Transfer

These data are useful for epidemiological studies, and also can be important in accessing certain
Check one box only
None/no patient or refused treatment
D Provider Impression/Assessment
types of Federal or State funds directed to specific racial or ethnic groups.
10
11
12
13
14
15
16
17

18
19
20
21
22
23
24
25

Abdominal pain
Airway obstruction
Allergic reaction
Altered LOC
Behavioral/psych
Burns
Cardiac arrest
Cardiac dysrhythmia
Age or Date of Birth

YYYY

Chest pain
Diabetic symptom
Do not resuscitate
Electrocution
General illness
Hemorrhaging/bleeding
Hyperthermia
Hypothermia

26
27
28
29
30
31
32
33

Hypovolemia
Inhalation injury
Obvious death
OD/poisoning
Pregnancy/OB
Respiratory arrest
Respiratory distress
Seizure

34
35
36
37
38
00

Sexual assault
Sting/bite
Stroke/CVA
Syncope
Trauma
Other

Section G: Human Factors Contributing to Injury
and Other Factors

Race
1
2
3
4
5

White
Black, African American
Am. Number
Indian, Alaska Native
Exposure
Incident
Asian
Native Hawaiian, Other Month
Pacific Islander
Time Arrived at Patient
0
Other, multiracial
U
Undetermined
Time of Patient Transfer

Human Factors
None
Contributing to Injury
NFIRS–6
Delete

Other
Factors

None

Check all applicable boxes
EMS
If an illness, not an
Change
injury, skip G2 and
Asleep
1
OR
go to H3
Day
Year
Hour/Min
Unconscious
2
ent Number
C Date/Time
Possibly impaired by alcohol
3
Check if same date
Possibly impaired by drug
4
1
Month
Accidental
Day
Year
as
Alarm date
Possibly mentally disabled
5
2
Self-inflicted
Physically
disabled
6 patient
3
Inflicted, not self
Gender
Ethnicity
Check one box only
None/no
or refused
treatment
sment
E2
F2 1
Physically restrained
7
Hispanic or Latino
34
Hypovolemia
18 1
26
Sexual assault
Chest 2painFemale
Unattended
person
8
Male
2
Non
Hispanic or Latino
35
19
Inhalation injury
27
Sting/bite
Diabetic symptom
36
Obvious death Injury Type
20 Body
28
Stroke/CVA
Do Site
not resuscitate
Cause of
of Injury
H3 Illness/Injury
H
H2 List one
37 type
211 List up
291
OD/poisoning
Syncope
body
site listed under H1
Electrocution
MM injury
DDfor each
YYYY
to five body sites
38
Pregnancy/OB
22
Trauma
General illness
A 30
Date
Station
Incident Number
Exposure
State
arrest Incident00
23
Other
Hemorrhaging/bleeding 31 FDID Respiratory
Cause of illness/injury
24
Respiratory distress
32
Hyperthermia
Month
of Patients
Patient Number
25
Seizure
Hypothermia
C Date/Time
B 33 Number

cident Date
Age

Months (for infants)

Station

Use Block G to clarify patient circumstances that may have contributed to the injury/illness. Mark
Delete
as many boxes as are applicable. This information can be important to injury researchers who Change
plan
injury-reduction programs based on human factors.
Day

Year

NFIRS–6

EMS

Hour/Min

Time Arrived at Patient

Race
1
2
3
4
01
5

Human Factors
None
Contributing to Injury
Provider
Impression/Assessment
Check
all applicable boxes

Use a separate
form for each patient
1

White
Black, African American
Procedures
UsedNative
Am.
Indian, Alaska
Asian
Airway insertion
Native Hawaiian, Other
Anti-shock
trousers
Pacific
Islander
Assist
ventilation
Other,
multiracial
Undetermined
Bleeding control

Check if same date

as Alarm date
Other
Factors

Check one box only

None Time of Patient Transfer
None/no patient or refused treatment

If an illness, not an
Cardiac Arrest
Safety
None K
injury,
skip G2 and 26
Asleep
Equipment
34
Hypovolemia
18
Sexual assault
Chest
pain
Check
all applicable boxes
10 1 14 Abdominal
pain
Intubation (EGTA)
go to H3
Unconscious
35
19
Inhalation injury
27
Sting/bite
Diabetic
11 2 15 Airway
obstruction
Used or symptom
deployed by patient.
02
Intubation
(ET)
Pre-arrival arrest?
1
Checkresuscitate
all applicable boxes.
Possiblyreaction
impaired by alcohol
3 16 Allergic
36
Obvious
death
20
28
Stroke/CVA
Do
not
12
03
0
IO/IV therapy
If pre-arrival arrest, was it:
Possibly
impaired by drug
37
1
Accidental
21
29
OD/poisoning
Syncope
Electrocution
13 4 17 Altered
LOC
U
04
Medications
therapy
1
Safety/seat belts
Possibly mentally disabled
5 18 Behavioral/psych
38
2
1 Pregnancy/OB
Witnessed?
Self-inflicted
22
30
Trauma
General
illness
14
Burn
care
05
Oxygen therapy
2
Child safety seat
Physically disabled
00
3
Inflicted, not self 31
arrest
Other
Ethnicity
Hemorrhaging/bleeding
15 6 19 Burns
Bystander
CPR?
2 Respiratory
Cardiac pacing
OB care/delivery 23
3
2 06
Airbag
Physically
restrained 24
arrest
Respiratory
distress
32
Hyperthermia
16 7 20 Cardiac
Hispanic or Latino
Cardioversion
(defib) manual
071
Prearrival instructions 4
Helmet
Post-arrival arrest?
Unattended
person
dysrhythmia
33 2 Seizure
Non Hispanic or Latino
Hypothermia
Chest/abdominal
thrust 17 8 21 Cardiac
082
Restrain patient 25
5
Protective clothing
2 22
CPR
09
Initial
Arrest
Rhythm
Spinal
Flotation
device
Human
Factors
Age or Date
of immobilization
Birth
Race6
None
Cause
of
None
Injury 1Type23
Cricothyroidotomy
F
1
G
1 Contributing to Injury
G2 Other
10
Splinted
extremities
H
3
0
Other
H2 List oneEinjury
Factors
Illness/Injury
type for each body site listed under H1
1
White
1
V-Fib/V-Tach
24
Defibrillation by AED
11
Suction/aspirate 2
U
Undetermined
Black,
African
American
Check
boxes
0 all applicable
If an illness, not an
Other
Months
(for infants)
EKG monitoring
12
Other
00
3
Am. Indian, Alaska Native
injury, skip G2 and
Undetermined
Age
1 U Asleep
4
Asian
Extrication
13
Cause of illness/injury
OR
go to H3
5
Native Hawaiian,
Other
Unconscious
2
Pacific Islander
by alcohol
3EMS Possibly impaired
Patient Status
Highest Level of Care
Initial Level of
Not
transported
None
0 M Other, multiracial
L1 Provider
LMonth
2 Provided On Scene
N 4Disposition
Possibly impaired by drug
1
Accidental
Day
Year
U 1 Undetermined
Improved
Possibly mentally disabled
5
2
Self-inflicted
1
First Responder
1
FD
transport
to
ECF
2
Remained same
1
First Responder
Physically disabled
3
Inflicted, not self
Gender
Ethnicity
2
EMT-B (Basic)
26
Non-FD transport
3
Worsened
2
EMT-B
(Basic)
E
F
2
eck all applicable boxes
Cardiac Arrest
2
Safety
No treatment
Physically restrained
7
1 K Hispanic or Latino
3
EMT-I (Intermediate)
None
J
FD
attend
3
Non-FD
trans/
3
EMT-I (Intermediate)
Check if: Check all applicable boxes
Unattended person
Female
2
14 EMT-PIntubation
Male Equipment
2
Non Hispanic or Latino
4
(Paramedic)
(EGTA)4 1
Non-emergency
transfer
48
EMT-P (Paramedic)
1
Pulse
on transfer
15 OtherIntubation
0
Used
or
deployed
by
patient.
provider (ET) 0
Pre-arrival
arrest?
Other
0
1
Other
provider
Check
all applicable boxes.
2
Cause of
No pulse on transfer
Body Site of Injury
Injury Type
N 16 No Training
Revision 01/01/04
IO/IV therapy
If pre-arrival arrest, was
H3 Illness/Injury
H1 List up to five body sites
Hit:2 List one injury type for each bodyNFIRS–6
site listed under H1
17
Medications therapy
1
Safety/seat belts
1
Witnessed?
18
Oxygen therapy
2
Child safety seat
Bystander CPR?
2
19
OB care/delivery
3
Airbag
Cause of illness/injury
nual 20
Prearrival instructions 4
Helmet
Post-arrival arrest?
2
21
Restrain patient
5
Protective clothing
22
Initial Arrest Rhythm
Spinal immobilization 6
Flotation device
23
Splinted extremities
0
Other
1
V-Fib/V-Tach
24
Suction/aspirate
U
Undetermined
0 boxesOther
Procedures Used
Check all applicable
Cardiac Arrest
No treatment
Other
00
I
None K
J Safety
U
Undetermined
Equipment
Check all applicable boxes
14
Airway insertion
01
Intubation (EGTA)
15
Anti-shock
trousers
Used
or
deployed
by
patient.
02
Intubation (ET)
Pre-arrival arrest?
1
Check all applicable boxes.
Patient Status
Highest Level of Care
EMS
16
Not transported
None
03M Assist ventilation
IO/IV therapy
L2 Provided On Scene
If pre-arrival arrest, was it:
N
Disposition
17
control
04 1 Bleeding
Medications therapy
Improved
1
Safety/seat belts
1
Witnessed?
1 18 FD transport
ECF
care same
05 2 Burn
Oxygen to
therapy
Remained
1
First Responder
2
Child safety seat
Bystander CPR?
2
19
2
Non-FD
transport
Cardiac
pacing
06
OB care/delivery
3
Worsened
2
EMT-B (Basic)
3
Airbag
attend
3 20 Non-FD
trans/FDinstructions
(defib) manual
07 CheckCardioversion
Prearrival
3
EMT-I (Intermediate)
4
Helmet
if:
Post-arrival arrest?
2
transfer
4 21 Non-emergency
Chest/abdominal thrust
08
Restrain patient
4
EMT-P (Paramedic)
5
Protective clothing

Check all applicable boxes

No treatment

Use Block G to address other factors such as accidental, self-inflicted, or inflicted, not self that affect
how the injury/illness occurred. Data can be used to show number comparisons between accidental
and self-inflicted incidents.

Section H: Body Site of Injury, Injury Type,
and Cause of Injury/Illness

6-7

19
20
21
22
23
24
25

Diabetic symptom
Do not resuscitate
Electrocution
General illness
Hemorrhaging/bleeding
Hyperthermia
Hypothermia

35
36
37
38
00

Inhalation injury
Obvious death
OD/poisoning
Pregnancy/OB
Respiratory arrest
Respiratory distress
Seizure

Sting/bite
Stroke/CVA
Syncope
Trauma
Other

NFIRS 5.0 Self-Study Program

Human
You can record
up toFactors
five body sitesNone
in Block
H1. Describe
the body site injured and its corresponding
None
G1 Contributing
G2 Other
to Injury
Factors
injury type,Checklisting
the body site with the most serious injury first. H2 links the type of each injury
all applicable boxes
If an illness, not an
noted to each
body
injury, skip G2 and
Asleepsite.
1

Race

1
2
3
4
5

27
28
29
30
31
32
33

White
Black, African American
Am. Indian, Alaska Native
Asian
Native Hawaiian, Other
Pacific Islander
Other, multiracial
Undetermined

Unconscious

Unattended person

go to H3

Site and type
of
injury
are crucial
Possibly
impaired
by alcoholdata elements that will enable EMS planners to identify the
3
0
Possibly
impaired by
4
Accidental
types of injuries
experienced
bydrug
patients1 using
the EMS system. These data also are used to analyze
U
Possibly mentally disabled
5
2
Self-inflicted
the correlation
betweendisabled
injury assessment
inInflicted,
the field
and actual injuries as evaluated in medical
Physically
6
3
not self
Ethnicity
Physically
restrained
7
receiving
facilities.
1
Hispanic or Latino
2

Non Hispanic or Latino

Injury Type

List one injury type for each body site listed under H1

Cause of
Illness/Injury

Cause of illness/injury

all applicable boxes

14
15
16
17
18
19
ual 20
21
22
23
24
00

Enter
a code in Block
H3 to capture the Cardiac
specificArrest
cause of the illness/injury. Data analysis provides an
Safety
No treatment
None K
J
understanding ofEquipment
the conditions causing
the
injury.
Check
all applicable
boxes It also assists with planning treatments in the
Intubation (EGTA)
Used or deployed
by patient.
field
illness/injury
programs.
Intubation
(ET)and developing
Pre-arrival arrest?
1
Check all applicable boxes.
IO/IV therapy
Medications therapy
1
Safety/seat belts
Oxygen therapy
2
Child safety seat
Cause of Illness/Injury
Codes
OB care/delivery
3
Airbag
Prearrival instructions 4
Helmet
Restrain patient
5 Exposure
Protective clothing
10 Chemical
Spinal immobilization 6
Flotation device
11
Drug
Poisoning
Splinted extremities
0
Other
12 Fall U
Suction/aspirate
Undetermined
13 Aircraft related
Other

14
Highest Level of Care15
Provided On Scene 16

Bite, includes animal bites
Bicycle accident
Patient Status
None M
Building collapse/construction
1
Improved
accident
2
Remained same
First Responder
Drowning
3
Worsened
EMT-B (Basic) 17
18 Electrical
shock
EMT-I (Intermediate)
Check if:
EMT-P (Paramedic)
19 Cold1
Pulse on transfer
Other provider

No pulse on transfer

If pre-arrival arrest, was it:

Witnessed?

Bystander CPR?
Post-arrival arrest?

20 Heat
Arrest Rhythm
21 Initial
Explosives
22 1 FireV-Fib/V-Tach
and flames
Other
23 0 Firearm
Undetermined
25 U Fireworks
26 Lightning
EMS
Machinery Not transported
N 27
Disposition
28
Mechanical suffocation
1
FD transport to ECF
29
Motor vehicle
accident
2
Non-FD
transport
Motor vehicle
accident,
attend
330
Non-FD
trans/FD
Non-emergency
transfer
4
pedestrian
0

Non-traffic vehicle (off-road)
accident
32 Physical assault/abuse
33 Scalds/other thermal
34 Smoke inhalation
35 Stabbing assault
36 Venomous sting
37 Water transport
00 Other cause
UU Unknown

Other

NFIRS–6 Revision 01/01/04

Example:
Patient with two stab wounds in different body sites and a blunt trauma injury to another body site.
Block H1

Block H2

Block H3

(2) neck and shoulder

(18) puncture/stab

(35) stabbing

(7) lower extremities

(18) puncture/stab

(35) stabbing

(1) head

(11) blunt injury

(13) assault

The system captures each separate injury related to a particular body site for as many as five injuries.

6-8

A
B

FDID

Number of Patients

Incident Date

State

Patient Number

Station

Female

Incident Number

Body Site of Injury

Non Hispanic or Latino
Exposure

Month

Change8

YearInjury

Day

Date/Time
1 List up to five body sites
CH
Time Arrived at Patient
Check if same date
NFIRS 5.0 Self-Study Program
as Alarm date

Unattended person
EMS

Type
Hour/Min

List one injury type for each body site listed under H1

Cause
Illnes

Time of Patient Transfer

Use a separate form for each patient

Male

Provider Impression/Assessment

Check one box only

None/no patient or refused treatment

Section I: Procedures Used

Cause of illnes

34
26
Hypovolemia
Sexual assault
Chest pain
35
Inhalation injury
27
Sting/bite
Diabetic symptom
36
Obvious death
28
Stroke/CVA
Do not resuscitate
37
29Used OD/poisoning
Electrocution Procedures
Check all applicable boxes
Cardiac Arrest
NoSyncope
treatment
I
None K
J Safety
38
Pregnancy/OB
30
Trauma
General illness Airway insertion
Equipment
Check all applicable bo
14
01
Intubation (EGTA)
00
Respiratory arrest
31trousers
Other
Hemorrhaging/bleeding
15
Anti-shock
Used or deployed by patient.
02
Intubation (ET)
Pre-arrival arr
1
Check all applicable boxes.
32
Respiratory distress
Hyperthermia Assist ventilation
16
03
IO/IV therapy
If pre-arrival arrest, was i
33
Seizure
Hypothermia
17
Bleeding control
04
Medications therapy
1
Safety/seat belts
1
Witnessed
Burn care
05
Oxygen
2
Child safety seat
Human Factors 18
Age or Date of Birth
Race
None therapy
Other
None
Bystander
2
E1
F1
G1 Contributing to Injury
G2 Factors 3
19
Cardiac pacing
06
OB care/delivery
Airbag
1
White
20
Cardioversion
(defib)
manual
07
Prearrival instructions 4
Helmet
2
Black, African American
Post-arrival a
2
Check all applicable boxes
If an illness, not an
Months (for infants)
21
Chest/abdominal thrust
3
Am. Indian, Alaska
08 Native
Restrain patient
5
Protective clothing
injury,
skip
G
2
and
Asleep
Age
1
4
Asian
22
CPR
09
Initial Arrest Rhyth
Spinal immobilization 6
Flotation device
OR
go to H3
5
Native Hawaiian, Other
Unconscious 23
2
Cricothyroidotomy
10
Splinted
extremities
0
Other
Pacific Islander
Possibly impaired
3 by AED
1
V-Fib/V-Tach
24 by alcohol
Defibrillation
11
Suction/aspirate
0
Other, multiracial
U
Undetermined
Possibly
impaired
by drug
4
1
0
Month
Other
Accidental
Day
Year
EKG monitoring
U
Undetermined12
Other
00
Possibly mentally disabled
2
U
Undetermin
Self-inflicted
Extrication5
13
Physically disabled
6
3
Inflicted, not self
E2 Gender
F2 1Ethnicity
Physically restrained
7
Patient Status
Highest Level of Care
Hispanic or Latino
Level of
EMS
None M
Not t
L1 Initial
L2 Provided
N Disposition
Unattended
person On Scene
Female
8
1
Male 2
2
Non Hispanic or Provider
Latino
1
Improved
1
First Responder
1
FD transport to
2
1
First Responder
Cause
ofRemained same
Body Site of Injury
Injury(Basic)
Type
2 H2 EMT-B
2
Non-FD transpo
H
3
3
Worsened
H1 List up to five body sites
2
EMT-B
(Basic)
Illness/Injury
List one injury type for each body site listed under H1
3
EMT-I (Intermediate) 3
3
Non-FD trans/FD
EMT-I (Intermediate)
Check if:
4
EMT-P (Paramedic)
Non-emergency
4
4
EMT-P (Paramedic)
1
Pulse on transfer
0
Other provider
Other
0
0
Other provider
Cause of2
illness/injury
No pulse on transfer
N
No Training
NFIRS–6 Rev
10
11
12
13
14
15
16
17

18
19
20
21
22
23
24
25

Abdominal pain
Airway obstruction
Allergic reaction
Altered LOC
Behavioral/psych
Burns
Cardiac arrest
Cardiac dysrhythmia

Many possible procedures are listed in Section I. Procedures are defined as anything done to assess or
treat the patient. Mark all applicable boxes to document the procedures either attempted or actually
performed during the course of patient care.

Section J: Safety Equipment

I
01
02
03
04
05
06
07
08
09
10
11
12
13

L1
1
2
3
4
0
N

Procedures Used

Check all applicable boxes

14
15
16
17
18
19
20
21
22
23
24
00

No treatment

Intubation (EGTA)
Intubation (ET)
IO/IV therapy
Medications therapy
1
Oxygen therapy
2
OB care/delivery
3
Prearrival instructions 4
Restrain patient
5
Spinal immobilization 6
Splinted extremities
0
Suction/aspirate
U
Other

Safety
Equipment

None

Cardiac Arrest

Check all applicable boxes

Used or deployed by patient.
Check all applicable boxes.

Pre-arrival arrest?

If pre-arrival arrest, was it:

Safety/seat belts
Child safety seat
Airbag
Helmet
Protective clothing
Flotation device
Other
Undetermined

Witnessed?

Bystander CPR?
Post-arrival arrest?

Initial Arrest Rhythm
1
0
U

V-Fib/V-Tach
Other
Undetermined

If the patientHighest
was Level
usingof Care
any safety equipment
at the time of EMS
the injury record a description of the
Patient Status
Not transported
None M
N Disposition
type usedL2inProvided
SectionOnJ.Scene
1
Improved

Initial Level of
Provider
First Responder
EMT-B (Basic)
EMT-I (Intermediate)
EMT-P (Paramedic)
Other provider
No Training

Remained same

No pulse on transfer

FD transport to ECF

First Responder
Nine options
are
provided. These data
important information
whether or not appro2
Non-FDabout
transport
3 provide
Worsened
2
EMT-B (Basic)
3
Non-FD
trans/FD attend
3
EMT-I (Intermediate)
priate safety
devices
are being used.Check
This
is
especially
important
in
industrial
and motor vehicle
if:
Non-emergency transfer
4
4
EMT-P (Paramedic)
1
on transfer
incidents,0 which
are regulated by FederalPulse
agencies
and local0and State
Other laws.
Other provider
NFIRS–6 Revision 01/01/04

Researchers, consumer groups, and manufacturers use these data to study the effectiveness of safety devices
in preventing injuries and reducing deaths. This information also is important to use when improvements
are being made to existing safety devices, or when new safety devices are being developed.

6-9

Non Hispanic or Latino

Unattended person

Injury Type
List one injury type for each body site listed under H1

Provider Impression/Assessment

10
Abdominal pain
Cause of
11
obstruction
HAirway
3 Illness/Injury
12
Allergic reaction
NFIRS
Self-Study
13 5.0Altered
LOCProgram
14
Behavioral/psych
Cause of illness/injury
15
Burns
Cardiac
arrest
16
Cardiac
dysrhythmia
17
MM
DD
YYYY

None

Check one box only

18
19
20
21
22
23
24
25

Chest pain
Diabetic symptom
Do not resuscitate
Electrocution
General illness
Hemorrhaging/bleeding
Hyperthermia
Hypothermia

Section K: Cardiac Arrest
A

Check all applicable boxes

14
15
16
17
18
19
manual 20
21
st
22
23
24
00

L2
1
2
3
4
0

No treatment

Age or Date of Birth
Incident Date
Station
Exposure
Incident Number
State
E1 Cardiac
F1 Race
Arrest
Safety
1
White
None K
Month
Equipment
Check all applicable Date/Time
boxes
2
Black, African American
Number
of Patients
Patient Number
Months (for infants)

Patient Status

Highest Level of Care
Provided On Scene

3TimeAm.
Indian,
Alaska Native
Arrived
at Patient
4
Asian
5TimeNative
Hawaiian,
Other
of Patient
Transfer
Pacific Islander
0
Other, multiracial
U
Undetermined

34
35
36
37
38
00

Hypovolemia
Inhalation injury
Obvious death
OD/poisoning
Pregnancy/OB
Respiratory arrest
Respiratory distress
Seizure
NFIRS–6
Delete

EMS
Human Factors
Change
Contributing to Injury

FDID

Intubation (EGTA)
C
B
Used or deployed by patient.
Intubation (ET)
Age
Pre-arrival
arrest?
1
Check
if same date
Check all applicable boxes.
OR
as Alarm date
IO/IV therapy
Use a separate form for each patient
If pre-arrival arrest, was it:
Medications therapy
1
Safety/seat belts
1
Witnessed?
Check one box only
Oxygen therapy
D 2 Provider
ChildImpression/Assessment
safety seat
Month
Day
Year
Bystander CPR?
2
OB care/delivery
3
Airbag
18
Chest pain
10
Abdominal pain
Prearrival instructions 4
Helmet
Gender
arrest?
19
Diabetic symptom
11
Airway obstruction
E22 Post-arrival
F2
Restrain patient
Protective
clothing
20
Do not resuscitate
125
Allergic reaction
Initial Arrest
Rhythm
Spinal immobilization 6
Female
2
Male
Flotation
device
21 1
Electrocution
13
Altered LOC
Splinted extremities
Other
221
General
illness
140
Behavioral/psych
V-Fib/V-Tach
Suction/aspirate
Body
Site of Injury
Undetermined
23
Hemorrhaging/bleeding
15U
Burns
0 1 ListOther
H
Other
up to five body sites
Cardiac arrest
24U
Hyperthermia
16
Undetermined
Cardiac dysrhythmia 25
Hypothermia
17

26
27
28
29
30
31
32
33

Day
Year
Hour/Min
Check all applicable boxes

Asleep
1
Unconscious
2
Possibly impaired by alcoh
3
None/no patient
or refused
treatment
Possibly
impaired
by drug
4
Possibly
mentally
5
34
Sexual assault disabled
Physically
356
Sting/bitedisabled
Physically
restrained
367
Stroke/CVA
Unattended
378
Syncope person

26
Hypovolemia
Ethnicity
Inhalation injury
27
1
Hispanic
or death
Latino
28
Obvious
2
Non
Hispanic or Latino
29
OD/poisoning
38
30
Pregnancy/OB
Trauma
Injury00
Type
Respiratory arrest
31
Other
H2 List one injury
type for each body site listed under H1
32
Respiratory distress
33
Seizure

Human Factors
Age or Date of Birth
Race
Not transported
None M
None
Other
None
N
This section
is
to indicate if patient
cardiac arrest
was pre-Gor
postarrival
on the scene
Eused
1
F1 Disposition
1 Contributing
Gof2 an
to Injury
Factors
1
Improved
1
White
incident. If it2 occurred
pre-arrival,
you
indicate
or allnot
it was witnessed and/orIf an
if illness, not an
1 2 should
FD
transport
to
ECFwhether Check
Black,
African
American
Remained
same
applicable boxes
First Responder
Am. Indian,
Alaska Native
2 3 Non-FD
transport
3
Worsened
EMT-B (Basic)
injury, skip G2 and
bystanders performed
CPR.
Asleep
Age
1
4
Asian
3
Non-FD trans/FD attend
EMS

Months (for infants)

EMT-I (Intermediate)
EMT-P (Paramedic)
Other provider

Check if:

Native Hawaiian, Other

go to H3

Unconscious

Procedures
Non-emergency
transfer Check all applicable boxes
4
Safety
No treatment
Pacific
IslanderUsed
I rhythm
None
impaired
byV-Fib/V-Tach,
alcohol J
You also should
record
initial arrest
by checking
the3 boxPossibly
next to
either
1
Pulse on the
transfer
0 Other
Other, multiracial
Equipment
0 01
14
Airway
insertion
Possibly
impaired
by
drug
Intubation
(EGTA)
4
1
Month
2
Accidental
Day
Year
No
pulse
on
transfer
U
Undetermined
Other, or Undetermined.
Anti-shock trousers
deployed by patient.
02
mentally
disabled
Intubation
(ET)
5 15 Possibly
2 Used orSelf-inflicted
NFIRS–6 Revision 01/01/04

Check all applicable boxes.

16 Physically
disabled
IO/IV therapy

Assist ventilation

06
07
08
09
10
11
12
13

19
Cardiac pacing
OB care/delivery
3
Cardioversion (defib)
manual
Prearrival instructions 4
Injury
Type20
H2thrust
List one injury type21
for each body
site listed under
H1
Chest/abdominal
Restrain
patient
5
22
CPR
Spinal immobilization 6
23
Cricothyroidotomy
Splinted extremities
0
24
Defibrillation by AED
Suction/aspirate
U
EKG monitoring
Other
00
Extrication

3
Inflicted, not self
Gender
F2 041Ethnicity
Data from thisEsection
are used to evaluate
prehospital
CPR and the7 effect
ofMedications
cardiac
care
on reducing
2
17 Physically
Bleeding
control
restrained
therapy
1
Safety/seat belts
Hispanic or Latino
Burn
care or Latino
05
Oxygenperson
therapy
Female
8 18 Unattended
1
Male 2
2
morbidity.
2
Non Hispanic
Child safety seat

Body Site of Injury

Procedures Used

List up to five body sites

Section L: Initial Level of Provider and
Highest Level of Care Provided on Scene

01
02
03
04
05
06
07
08
09
10
11
12
13

Initial Level of

Provider
Check all applicable
boxes

1
Airway insertion
2
Anti-shock trousers
3
Assist ventilation
4
Bleeding control
0
Burn care
N
Cardiac pacing
Cardioversion (defib) manual
Chest/abdominal thrust
CPR
Cricothyroidotomy
Defibrillation by AED
EKG monitoring
Extrication

14
15
16
17
18
19
20
21
22
23
24
00

No treatment

Highest Level of Care
ProvidedSafety
On Scene

Airbag
Cause of

Helmet
H
3 Illness/Injury

Protective clothing
Flotation device
Other
Cause of illness/injury
Undetermined

M Patient Status
Cardiac Arrest
None 1 K Improved

None

First Responder
FirstEquipment
Responder
Intubation (EGTA) 1
EMT-B (Basic)
2
EMT-B
(Basic)
Used or
deployed by patient.
Intubation (ET)
EMT-I (Intermediate) 3
Check all applicable boxes.
EMT-I (Intermediate)
IO/IV therapy
EMT-P (Paramedic)
4
(Paramedic)
Medications therapy
1 EMT-P
Safety/seat
belts
Other provider
OtherChild
provider
Oxygen therapy 0
2
safety
seat
No Training
OB care/delivery
3
Airbag
Prearrival instructions 4
Helmet
Restrain patient
5
Protective clothing
Spinal immobilization 6
Flotation device
Splinted extremities
0
Other
Suction/aspirate
U
Undetermined
Other

2
3

Check all applicable
boxes
Remained
same
Worsened
Pre-arrival arrest?

CheckIfif:pre-arrival arrest, was it:

1
2

on transfer
1 Pulse
Witnessed?
No pulse on transfer
Bystander CPR?
2
2

Post-arrival arrest?

Block L1 is used to collect data about the training level of the fire department responders who
provided the initial care. Researchers can use these data to determine the effectiveness of Initial
care Arrest
and Rhythm
V-Fib/V-Tach
measure any trends in the quality of prehospital care being provided by fire departments. 1

L1
1
2
3
4
0
N

Initial Level of
Provider
First Responder
EMT-B (Basic)
EMT-I (Intermediate)
EMT-P (Paramedic)
Other provider
No Training

L2
1
2
3
4
0

Highest Level of Care
Provided On Scene
First Responder
EMT-B (Basic)
EMT-I (Intermediate)
EMT-P (Paramedic)
Other provider

6-10

None

Patient Status

1
2
3

Improved
Remained same
Worsened

Check if:

1
2

Pulse on transfer
No pulse on transfer

0
U

N
1
2
3
4
0

Other
Undetermined

EMS
Disposition

Not transported

FD transport to ECF
Non-FD transport
Non-FD trans/FD attend
Non-emergency transfer
Other
NFIRS–6 Revision 01/01/04

1
2
3
4
0

E
D

23
24
25

mia

Respiratory arrest
Respiratory distress
Seizure

Hemorrhaging/bleeding 31
32
Hyperthermia
33
Hypothermia

Cause of illness/injury

Other

Human Factors
None 5.0 Self-Study
None
NFIRS
Program
G2 Other
No treatment
to Injury
Factors
None
J Safety
Equipment
2
Black,
African
American
14all applicable
Airway
insertion
01
Intubation
(EGTA)
Check
boxes
If
an
illness,
not
an
3
Am. Indian, Alaska Native
15 Asleep
Anti-shock trousers
Used or deployed
02
Intubation (ET)
injury,
skip by
Gpatient.
2 and
1
4
Asian
2
Check all applicable boxes.
16 Unconscious
Assist
ventilation
03
IO/IV
therapy
go
to
H
3
5
Native
Hawaiian,
Other
2
17 Possibly
Bleeding
control
Islander
04 Pacific
Medications
Safety/seat belts
impairedtherapy
by alcohol 1
3
0
Other,
18 Possibly
Burnmultiracial
care
05
Oxygen
therapy
safety seat
impaired
by drug 2 1 Child
4
Accidental
U
Undetermined
19 Possibly
Cardiac pacing
06
OB care/delivery
mentally disabled 3 2 Airbag
5
Self-inflicted
20 Physically
Cardioversion (defib) manual
07
Prearrival
instructions 4 3 Helmet
disabled
6
Inflicted, not self
F2 081Ethnicity
21 Physically
Chest/abdominal thrust
Restrain
patient
5
Protective clothing
restrained
7
Hispanic or Latino
22 Unattended
CPR
09
Spinal immobilization
6
Flotation device
person
8
2
Non Hispanic or Latino
23
Cricothyroidotomy
10
Splinted extremities
0
Other
24
Defibrillation by AED
11
Suction/aspirate
U
Cause of
Undetermined
Injury Type
H3 Illness/Injury
H2 List one injury type00for each body
EKG monitoring
12
Other
site listed under H1
Extrication
13

F1 Race
Procedures Used
1I White

1 Contributing
Check all applicable
boxes

Cardiac Arrest
Check all applicable boxes

Pre-arrivalresponders
arrest?
1
Block L is used to gather training-level information on the fire department
who proIf pre-arrival arrest, was it:
vided the highest level of care at the scene of an incident. This knowledge can help determine what
kind of effect there is on patient care in the field when responders 12haveWitnessed?
higher levels of training/
Bystander CPR?
certification.
2

Post-arrival arrest?

Initial Arrest Rhythm

Section M: Patient Status
0
Other

Patient Status
Highest Level of Care
Initial Level of
Cause of illness/injury
None M
L2 Provided On Scene
Provider
1
Improved
1
First Responder
2
Remained same
1
First Responder
2
EMT-B (Basic)
3
Worsened
2
EMT-B (Basic)
3
EMT-I (Intermediate) 3
EMT-I (Intermediate)
Check if:
4
EMT-P (Paramedic)
Check all applicable boxes
Cardiac Arrest
Safety
4
No treatment
(Paramedic)
None 1 K Pulse on transfer
JEMT-P
0
Other provider
Equipment
0
Check all applicable boxes
Other
provider
2
Intubation (EGTA)
No
pulse on transfer
N 14 No Training
15
Used or deployed by patient.
Intubation (ET)
Pre-arrival
arrest?
1
Check all applicable boxes.
16
IO/IV therapy
If pre-arrival arrest, was it:
17
Medications therapy
1
Safety/seat belts
1
Witnessed?
18
Oxygen therapy
2
Child safety seat
Bystander CPR?
2
19
OB care/delivery
3
Airbag
b) manual 20
Prearrival instructions 4
Helmet
Post-arrival arrest?
2
21
rust
Restrain patient
5
Protective clothing
22
Initial Arrest Rhythm
Spinal immobilization 6
Flotation device
23
Splinted extremities
0
Other
1
V-Fib/V-Tach
24
D
Suction/aspirate
U
Undetermined
0
Other
Other
00
U
Undetermined

e)
)

V-Fib/V-Tach

Undetermined

EMS
Disposition

1
2
3
4
0

Not transported

FD transport to ECF
Non-FD transport
Non-FD trans/FD attend
Non-emergency transfer
Other
NFIRS–6 Revision 01/01/04

Mark the box that indicates whether the patient Improved, Remained same, or Worsened while
under fire department care. This determination is made at the time of patient transfer. There is also a
box that should be marked whether or not the patient had a pulse on transfer.

Section N: Disposition

L2
1
2
3
4
0

Highest Level of Care
Provided On Scene
First Responder
EMT-B (Basic)
EMT-I (Intermediate)
EMT-P (Paramedic)
Other provider

None

Patient Status

1
2
3

Improved
Remained same
Worsened

Check if:

1
2

Pulse on transfer
No pulse on transfer

N
1
2
3
4
0

EMS
Disposition

Not transported

FD transport to ECF
Non-FD transport
Non-FD trans/FD attend
Non-emergency transfer
Other
NFIRS–6 Revision 01/01/04

There are six choices available for documenting the disposition of the patient. These data will allow
generation of reports that show the disposition for EMS responses, and can correlate various patient
treatments to patient outcomes. This section may help the fire service to look at what its EMS transport needs are.

SUMMARY
Nationally, EMS activities are a significant part of the total service being provided by fire departments.
The fire service can use the EMS Module to report all emergency medical incidents to which a fire
department unit responds. A separate EMS Module is used for each patient.

6-11

NFIRS 5.0 Self-Study Program

EXAMPLE: Injured Person
Directions: Read the call information in the example below.Then look at the completed EMS Module form. Look at each section
and follow along with the proper use of the information as applicable to the EMS Module.
Department FDID #TR200, Station #1, is dispatched on a medical call on May 1, 2002. A fire
department unit is dispatched to respond to the call at 0223 hours. The unit arrives at 1245 S.
First St., Brooklyn, WI 12345 at 0228 and is met by a 22-year-old white female. She has been
stabbed in the leg and is bleeding from the wound. Further examination reveals burns on one
arm. A first responder stops the bleeding, bandages the wound, and provides care for the burns.
The patient’s family chooses to provide transportation to the closest hospital for further treatment. She is transferred at 0256 hours. The incident number is 0001234.

6-12

NFIRS 5.0 Self-Study Program
TR200

FDID

YYYY

2002

001

Provider Impression/Assessment
18
19
20
21
22
23
24
25

Abdominal pain
Airway obstruction
Allergic reaction
Altered LOC
Behavioral/psych
Burns
Cardiac arrest
Cardiac dysrhythmia
Age or Date of Birth

0 2 2

Months (for infants)

Age

Month

Day

Gender

E2
1

Male

F2
2

X Female

Day

Year

Hour/Min

0228

Time of Patient Transfer

0256
None/no patient or refused treatment

34
35
36
37
38
00

Hypovolemia
Inhalation injury
Obvious death
OD/poisoning
Pregnancy/OB
Respiratory arrest
Respiratory distress
Seizure
Human Factors
Contributing to Injury

Sexual assault
Sting/bite
Stroke/CVA
Syncope
Trauma
Other

None

Asleep
Unconscious
Possibly impaired by alcohol
Possibly impaired by drug
Possibly mentally disabled
Physically disabled
Physically restrained
Unattended person

1
2
3

Injury Type

None

Accidental
Self-inflicted
X Inflicted, not self

List one injury type for each body site listed under H1

Lower Extremity
Upper Extremity

Other
Factors

If an illness, not an
injury, skip G2 and
go to H3

Check all applicable boxes

1
2
3
4
5
6
7
8

Hispanic or Latino
Non Hispanic or Latino

26
27
28
29
30
31
32
33

Ethnicity
1
2

EMS

Time Arrived at Patient

White
Black, African American
Am. Indian, Alaska Native
Asian
Native Hawaiian, Other
Pacific Islander
Other, multiracial
Undetermined

List up to five body sites

7
6

Exposure

Race
1
2
3
4
5

NFIRS–6

Delete
Change

Month

Date/Time

Chest pain
Diabetic symptom
Do not resuscitate
Electrocution
General illness
Hemorrhaging/bleeding
Hyperthermia
Hypothermia

Body Site of Injury

Incident Number

000

Check one box only

0
U

Year

Check if same date
as Alarm date

Use a separate form for each patient

10
11
12
13
14
15
16
17

0 0 0 1 2 3 4

Station

Patient Number

001

Incident Date

State

Number of Patients

1 8 Puncture/Stab
1 2 Burn

Cause of
Illness/Injury

3 2
Cause of illness/injury

Physical
Assault

Procedures Used

I
01
02
03
04
05
06
07
08
09
10
11
12
13

L1
1
2
3
4
0
N

X
X

Check all applicable boxes

Initial Level of
Provider
X First Responder
EMT-B (Basic)
EMT-I (Intermediate)
EMT-P (Paramedic)
Other provider
No Training

L2
1
2
3
4
0

14
15
16
17
18
19
20
21
22
23
24
00

No treatment

Highest Level of Care
Provided On Scene

First Responder
EMT-B (Basic)
EMT-I (Intermediate)
EMT-P (Paramedic)
Other provider

None

M
1
2
3

Safety
Equipment

6-13

Pre-arrival arrest?

If pre-arrival arrest, was it:

Safety/seat belts
Child safety seat
Airbag
Helmet
Protective clothing
Flotation device
Other
Undetermined

Improved
Remained same
Worsened

Check if:

1
2

Cardiac Arrest

Check all applicable boxes

Used or deployed by patient.
Check all applicable boxes.

Patient Status

None

Pulse on transfer
No pulse on transfer

Witnessed?

Bystander CPR?
Post-arrival arrest?

Initial Arrest Rhythm
1
0
U

N
1
2
3
4
0

V-Fib/V-Tach
Other
Undetermined

EMS
Disposition

Not transported

FD transport to ECF
Non-FD transport
Non-FD trans/FD attend
Non-emergency transfer
Other
NFIRS–6 Revision 01/01/04

NFIRS 5.0 Self-Study Program

EXERCISE SCENARIO 6.1: Unconscious Person
Directions: Read the call information in the exercise below. Use the information provided to complete the EMS Module form.
Compare your work to the answers provided on the completed EMS Module form. If your answers are different from the ones
provided, read over the EMS Module again.
A fire department first-responder unit, TR 100, Station 001, is dispatched at 1405 hours on April
1, 1997 to a medical call – incident #9704567. The unit is staffed with a driver, an officer, and an
EMT. They arrive at 210 W. Main Street, Minlo, WI 12345 at 1407 hours and reach the patient’s
side at 1410. They find a 22-year-old white male unconscious on the floor. His friends tell them
that he just shot up on heroin and has overdosed. The patient shows signs of shallow breathing,
pin-point pupils, and has a faint pulse. The EMT inserts an airway, administers oxygen, and assists
in ventilation.
A private medic unit arrives and the Paramedic administers a dose of Narcan. The patient responds
and begins breathing on his own. At 1440, the Paramedic determines that the patient has stabilized and arranges transport to an emergency room for further evaluation.

6-14

NFIRS 5.0 Self-Study Program
MM

FDID

YYYY
Station

Patient Number

Provider Impression/Assessment

10
11
12
13
14
15
16
17

Months (for infants)

Age

Month

E2
1

OR
Day

Male

F2
2

Female

Day

None/no patient or refused treatment

Human Factors
Contributing to Injury

Sexual assault
Sting/bite
Stroke/CVA
Syncope
Trauma
Other

None

Other
Factors

None

If an illness, not an
injury, skip G2 and
go to H3

Check all applicable boxes

Hispanic or Latino
Non Hispanic or Latino

34
35
36
37
38
00

Hypovolemia
Inhalation injury
Obvious death
OD/poisoning
Pregnancy/OB
Respiratory arrest
Respiratory distress
Seizure

Asleep
Unconscious
Possibly impaired by alcohol
Possibly impaired by drug
Possibly mentally disabled
Physically disabled
Physically restrained
Unattended person

1
2
3
4
5
6
7
8

Ethnicity

List up to five body sites

26
27
28
29
30
31
32
33

White
Black, African American
Am. Indian, Alaska Native
Asian
Native Hawaiian, Other
Pacific Islander
Other, multiracial
Undetermined

Body Site of Injury

Hour/Min

Time of Patient Transfer

Chest pain
Diabetic symptom
Do not resuscitate
Electrocution
General illness
Hemorrhaging/bleeding
Hyperthermia
Hypothermia

1
2

Year

Time Arrived at Patient

Race
1
2
3
4
5
0
U

Year

Gender

Month

Date/Time

EMS

Change

Exposure

Check one box only

18
19
20
21
22
23
24
25

Abdominal pain
Airway obstruction
Allergic reaction
Altered LOC
Behavioral/psych
Burns
Cardiac arrest
Cardiac dysrhythmia
Age or Date of Birth

Incident Number

Check if same date
as Alarm date

Use a separate form for each patient

NFIRS–6

Delete

Incident Date

State

Number of Patients

1
2
3

Injury Type

Accidental
Self-inflicted
Inflicted, not self

List one injury type for each body site listed under H1

Cause of
Illness/Injury

Cause of illness/injury

I
01
02
03
04
05
06
07
08
09
10
11
12
13

L1
1
2
3
4
0
N

Procedures Used

Check all applicable boxes

Airway insertion
Anti-shock trousers
Assist ventilation
Bleeding control
Burn care
Cardiac pacing
Cardioversion (defib) manual
Chest/abdominal thrust
CPR
Cricothyroidotomy
Defibrillation by AED
EKG monitoring
Extrication
Initial Level of
Provider
First Responder
EMT-B (Basic)
EMT-I (Intermediate)
EMT-P (Paramedic)
Other provider
No Training

L2
1
2
3
4
0

14
15
16
17
18
19
20
21
22
23
24
00

No treatment

Highest Level of Care
Provided On Scene
First Responder
EMT-B (Basic)
EMT-I (Intermediate)
EMT-P (Paramedic)
Other provider

None

Safety
Equipment

6-15

Pre-arrival arrest?

If pre-arrival arrest, was it:

Safety/seat belts
Child safety seat
Airbag
Helmet
Protective clothing
Flotation device
Other
Undetermined

Improved
Remained same
Worsened

Check if:

1
2

Cardiac Arrest

Check all applicable boxes

Used or deployed by patient.
Check all applicable boxes.

Patient Status

1
2
3

None

Pulse on transfer
No pulse on transfer

Witnessed?

Bystander CPR?
Post-arrival arrest?

Initial Arrest Rhythm
1
0
U

N
1
2
3
4
0

V-Fib/V-Tach
Other
Undetermined

EMS
Disposition

Not transported

FD transport to ECF
Non-FD transport
Non-FD trans/FD attend
Non-emergency transfer
Other
NFIRS–6 Revision 01/01/04

NFIRS 5.0 Self-Study Program
TR100

FDID

YYYY

1997

001

Provider Impression/Assessment

Age or Date of Birth

0 2 2

Months (for infants)

Age

Month

Day

Gender

Male

F2
2

Female

Day

Black, African American
Am. Indian, Alaska Native
Asian
Native Hawaiian, Other
Pacific Islander
Other, multiracial
Undetermined

EMS
Hour/Min

1410
1440

Time of Patient Transfer

26
27
28
29
30
31
32
33

Hispanic or Latino
Non Hispanic or Latino

34
35
36
37
38
00

Hypovolemia
Inhalation injury
Obvious death
OD/poisoning
Pregnancy/OB
Respiratory arrest
Respiratory distress
Seizure

Human Factors
Contributing to Injury

Sexual assault
Sting/bite
Stroke/CVA
Syncope
Trauma
Other

None

Asleep
Unconscious
Possibly impaired by alcohol
Possibly impaired by drug
Possibly mentally disabled
Physically disabled
Physically restrained
Unattended person

1
2
3

Injury Type

None

Accidental

X Self-inflicted
Inflicted, not self

List one injury type for each body site listed under H1

Internal

Other
Factors

If an illness, not an
injury, skip G2 and
go to H3

Check all applicable boxes

1
2
3
4
5
6
7
8

Ethnicity
1
2

Year

Time Arrived at Patient

X White

List up to five body sites

Exposure

None/no patient or refused treatment

Race
1
2
3
4
5

Body Site of Injury

X
X

NFIRS–6

Delete
Change

Month

Date/Time

Chest pain
Diabetic symptom
Do not resuscitate
Electrocution
General illness
Hemorrhaging/bleeding
Hyperthermia
Hypothermia

0
U

Year

Incident Number

000

Check one box only

18
19
20
21
22
23
24
25

Abdominal pain
Airway obstruction
Allergic reaction
Altered LOC
Behavioral/psych
Burns
Cardiac arrest
Cardiac dysrhythmia

Check if same date
as Alarm date

Use a separate form for each patient

10
11
12
13
14
15
16
17

9 7 0 4 5 6 7

Station

Patient Number

001

Incident Date

State

Number of Patients

Other

Cause of
Illness/Injury

1 1
Cause of illness/injury

Drug
Overdose

I
01
02
03
04
05
06
07
08
09
10
11
12
13

L1
1
2
3
4
0
N

Procedures Used

X
X

Check all applicable boxes

Initial Level of
Provider
First Responder
X EMT-B (Basic)
EMT-I (Intermediate)
EMT-P (Paramedic)
Other provider
No Training

L2
1
2
3
4
0

14
15
16
17
18
19
20
21
22
23
24
00

No treatment

Highest Level of Care
Provided On Scene

First Responder
EMT-B (Basic)
EMT-I (Intermediate)
EMT-P (Paramedic)
Other provider

None

M
1
2
3

Safety
Equipment

6-16

Pre-arrival arrest?

If pre-arrival arrest, was it:

Safety/seat belts
Child safety seat
Airbag
Helmet
Protective clothing
Flotation device
Other
Undetermined

Improved
Remained same
Worsened

Check if:

1
2

Cardiac Arrest

Check all applicable boxes

Used or deployed by patient.
Check all applicable boxes.

Patient Status

None

Pulse on transfer
No pulse on transfer

Witnessed?

Bystander CPR?
Post-arrival arrest?

Initial Arrest Rhythm
1
0
U

N
1
2
3
4
0

V-Fib/V-Tach
Other
Undetermined

EMS
Disposition

Not transported

FD transport to ECF
Non-FD transport
Non-FD trans/FD attend
Non-emergency transfer
Other
NFIRS–6 Revision 01/01/04

NFIRS 5.0 Self-Study Program

EXERCISE SCENARIO 6-2: MVA on I-95
Directions: Read the call information in the exercise below. Use the information provided to complete the entire EMS Module
form and other required forms. Compare your work to the answers provided in Appendix A. If your answers are different from
the ones provided, read over the EMS Module again.
The Alberta Fire Department (FDID #92188) received a call for an MVA on I-95 near mile
marker 73 and Exit 2B in Brunswick, Virginia, 23351 on May 3, 2005. The dispatcher assigned the
incident (#5455) to Engine Co. 2 and Truck 1 from Shift C. The units received the alarm at 11:58
p.m. and arrived at the scene in six minutes with 4 firefighters on each unit. The owner of the
vehicle, Mr. Robert L. Anderson, was driving to Emporia, Virginia, to return his son, Joseph, to his
mother. Mr. Anderson lives at 1630 Second Avenue, Jarrett, North Carolina, 24501. His telephone
number is 555-432-0987. He said that he was driving for 2 hours and became drowsy from a
prescription drug that he took; he lost control of the car and it crashed into the guardrail. He
called 9-1-1 from his cellular telephone. The vehicle was a 1999 Ford Explorer, Virginia License
Plate Number ACZ586, and VIN 1FBEU54X3ABC45634. Mr. Anderson, a 49-year-old black male,
was bleeding from the head. He cut his head when his car hit the guardrail. He was not wearing a safety belt and the airbag in the vehicle did not inflate. Firefighter Steve Cooke, EMT-Basic,
approached Officer Morrison at 12:06 a.m. Firefighter Cooke stopped the bleeding. No other
treatment was needed. Mr. Anderson’s overall status improved. The towing service provider gave
Mr. Anderson a ride from the incident. The last unit cleared the scene at 12:35 a.m. FF1 Steve B.
LaCivita, Badge No. 230, completed the report after returning to Station No. 1. Captain Ernest
Greene, Badge No. 100, was the officer in charge. The incident was in Census Tract 501.2, District
A05. The Virginia Department of Transportation, 23 Washington Street NE, Richmond, VA 23219,
manages Virginia highways.

6-17

NFIRS 5.0 Self-Study Program
MM

Delete

Incident Date

State

Location Type

Station

Incident Number

Exposure

NFIRS–1

Number/Milepost

Prefix

Basic

No Activity

Check this box to indicate that the address for this incident is provided on the Wildland Fire
Module in Section B, “Alternative Location Specification." Use only for wildland fires.

Street address
Intersection
In front of
Rear of
Adjacent to
Directions
US National Grid

Census Tract

Street or Highway

Street Type

Suffix

Apt./Suite/Room

City

State

ZIP Code

Cross Street, Directions or National Grid, as applicable

Incident Type

YYYY

Change
FDID

Aid Given or Received

None

Dates and Times

Midnight is 0000

Month

Check boxes if
dates are the
same as Alarm
Date.

Day

Year

Hour

Min

Shifts and Alarms
Local Option

ALARM always required

Shift or
Platoon

Alarm

Alarms

District

ARRIVAL required, unless canceled or did not arrive

1
2
3
4
5

Mutual aid received
Auto. aid received
Mutual aid given
Auto. aid given
Other aid given

Their FDID

Last Unit
Cleared

Resources

Primary Action Taken (1)

Apparatus

Personnel

Suppression
Additional Action Taken (2)

Civilian Fire Cas.–4
Fire Service Cas.–5
EMS–6
HazMat–7
Wildland Fire–8
Apparatus–9
Personnel–10
Arson–11

Check box if resource counts include aid
received resources.

Casualties

None

Deaths Injuries
Fire
Service
Civilian

H2
1
2
U

Detector
Required for confined fires.

Detector alerted occupants
Detector did not alert them
Unknown

H3
1
2
3
4
5
6
7
8
0

Special
Study Value

Estimated Dollar Losses and Values

LOSSES:

Required for all fires if known.
Optional for non-fires.

Property

Contents

None

PRE-INCIDENT VALUE: Optional

EMS
Other
Additional Action Taken (3)

Special
Study ID#

LAST UNIT CLEARED, required except for wildland fires

Check this box and skip this block if an
Apparatus or Personnel Module is used.

Fire–2
Structure Fire–3

Local Option

Controlled

Actions Taken

Completed Modules

Special Studies

CONTROLLED optional, except for wildland fires

Their
State

Their Incident Number

Arrival

Property

Contents

Hazardous Materials Release

None

Natural gas: slow leak, no evacuation or HazMat actions
Propane gas: <21-lb tank (as in home BBQ grill)
Gasoline: vehicle fuel tank or portable container
Kerosene: fuel burning equipment or portable storage
Diesel fuel/fuel oil: vehicle fuel tank or portable storage
Household solvents: home/office spill, cleanup only
Motor oil: from engine or portable container
Paint: from paint cans totaling <55 gallons
Other: special HazMat actions required or spill > 55 gal
(Please complete the HazMat form.)

Mixed Use
Property
10
20
33
40
51
53
58
59
60
63
65
00

Not mixed

Assembly use
Education use
Medical use
Residential use
Row of stores
Enclosed mall
Business & residential
Office use
Industrial use
Military use
Farm use
Other mixed use

Property Use
None
Structures
Church, place of worship
131
Restaurant or cafeteria
161
Bar/tavern or nightclub
162
Elementary school, kindergarten
213
High school, junior high
215
College, adult education
241
Nursing home
311
Hospital
331

341
342
361
419
429
439
449
459
464
519

Clinic, clinic-type infirmary
Doctor/dentist office
Prison or jail, not juvenile
1- or 2-family dwelling
Multifamily dwelling
Rooming/boarding house
Commercial hotel or motel
Residential, board and care
Dormitory/barracks
Food and beverage sales

539
571
579
599
615
629
700
819
882
891

Household goods, sales, repairs
Gas or service station
Motor vehicle/boat sales/repairs
Business office
Electric-generating plant
Laboratory/science laboratory
Manufacturing plant
Livestock/poultry storage (barn)
Non-residential parking garage
Warehouse

Outside
Playground or park
124
Crops or orchard
655
Forest (timberland)
669
Outdoor storage area
807
Dump or sanitary landfill
919
Open land or field
931

936
938
946
951
960
961
962

Vacant lot
Graded/cared for plot of land
Lake, river, stream
Railroad right-of-way
Other street
Highway/divided highway
Residential street/driveway

981
984

Construction site
Industrial plant yard

6-18

Look up and enter a
Property Use code and
description only if you
have NOT checked a
Property Use box.

Property Use
Code
Property Use Description
NFIRS–1 Revision 01/01/05

NFIRS 5.0 Self-Study Program
Person/Entity Involved

Local Option

Check this box if same
address as incident
Location (Section B).
Then skip the three
duplicate address
lines.

Business Name (if applicable)

Mr., Ms., Mrs.

First Name

Number

Prefix

Post Office Box

State

Area Code

Phone Number

Last Name

Suffix

Street or Highway

Street Type

Apt./Suite/Room

Suffix

City

ZIP Code

More people involved? Check this box and attach Supplemental Forms (NFIRS–1S) as necessary.

Owner

Local Option

Check this box if same
address as incident
Location (Section B).
Then skip the three
duplicate address
lines.

Same as person involved?
Then check this box and skip
the rest of this block.

Mr., Ms., Mrs.

Business Name (if applicable)

First Name

Number

Prefix

Post Office Box

State

Area Code

Phone Number

Last Name

Suffix

Street or Highway

Street Type

Apt./Suite/Room

Suffix

City

ZIP Code

Remarks:

Local Option

Fire Module Required?
Check the box that applies and then complete the Fire Module
based on Incident Type, as follows:
Complete Fire & Structure Modules
Complete Fire Module &
Section I, Structure Module
Basic Module Only
Confined 113–118
Complete Fire Module
Mobile property 120–123
Complete Fire Module
Vehicle 130–138
Complete Fire or Wildland Module
Vegetation 140–143
Outside rubbish fire 150–155 Basic Module Only
Complete Fire or Wildland Module
Special outside fire 160
Special outside fire 161–163 Complete Fire Module
Complete Fire or Wildland Module
Crop fire 170–173
Buildings 111
Special structure 112

ITEMS WITH A

MUST ALWAYS BE COMPLETED!

More remarks? Check this box and attach Supplemental Forms (NFIRS–1S) as necessary.

Authorization

Check box if
same as
Officer in
charge.

Officer in charge ID

Signature

Position or rank

Assignment

Month

Day

Year

Member making report ID

Signature

Position or rank

Assignment

Month

Day

Year

6-19

NFIRS 5.0 Self-Study Program

MM
FDID

YYYY

Incident Date

State

Station

Property Details

C
Not Residential

Incident Number

On-Site Materials
or Products

Change

Exposure

None

Enter up to three codes. Check one box for each code
entered.

On-Site Materials
Storage Use

On-site material (1)

1
2
3
4
U

Bulk storage or warehousing
Processing or manufacturing
Packaged goods for sale
Repair or service
Undetermined

On-site material (2)

1
2
3
4
U

Bulk storage or warehousing
Processing or manufacturing
Packaged goods for sale
Repair or service
Undetermined

1
2
3
4
U

Bulk storage or warehousing
Processing or manufacturing
Packaged goods for sale
Repair or service
Undetermined

Buildings not involved
Number of buildings involved

None

Less than one acre

Acres burned (outside fires)

On-site material (3)

D
D1
D2

Ignition

Area of fire origin

Heat source

D3
Item first ignited

Check box if fire spread was
confined to object of origin.

Cause of Ignition
Skip to
Section G

Check box if this is an exposure report.

Intentional
Unintentional
Failure of equipment or heat source
Act of nature
Cause under investigation
Cause undetermined after investigation

Factors Contributing to Ignition

3
4
5
None
6

Estimated age of
person involved

Required only if item first
ignited code is 00 or <70

Equipment Involved in Ignition
None

Age was a factor

Factor contributing to ignition (2)

None

Asleep
Possibly impaired by
alcohol or drugs
Unattended person
Possibly mentally disabled
Physically disabled
Multiple persons involved

1
2

Factor contributing to ignition (1)
Type of material first ignited

Human Factors
Contributing to Ignition

Check all applicable boxes

1
2
3
4
5
U

Fire

Complete if there were any significant amounts of
commercial, industrial, energy, or agricultural products or
or materials on the property, whether or not they became involved

Estimated number of residential living units in
building of origin whether or not all units
became involved

NFIRS–2

Delete

Equipment Power Source

Male

Fire Suppression Factors

Female

None

Enter up to three codes.

If equipment was not involved, skip to
Section G
Equipment Power Source

Equipment Involved

Brand
Model
Serial #

Equipment Portability
1

Portable

Stationary

Portable equipment normally can be moved by
one or two persons, is designed to be used in
multiple locations, and requires no tools to install.

Year

Mobile Property Involved

Not involved in ignition, but burned

Involved in ignition, but did not burn

Involved in ignition and burned

None

Fire suppression factor (1)

Fire suppression factor (2)

Fire suppression factor (3)

Mobile Property Type and Make

Local Use
Pre-Fire Plan Available
Some of the information presented in this report may be
based upon reports from other agencies:

Mobile property type

Mobile property make

Mobile property model

License Plate Number

Year

State

Arson report attached
Police report attached
Coroner report attached
Other reports attached

VIN

Structure fire? Please be sure to complete the Structure Fire form (NFIRS–3).
NFIRS–2 Revision 01/01/05

6-20

NFIRS 5.0 Self-Study Program
MM

FDID

YYYY
Station

Patient Number

Provider Impression/Assessment

10
11
12
13
14
15
16
17

Months (for infants)

Age

Month

E2
1

OR
Day

Male

F2
2

Female

Day

None/no patient or refused treatment

Human Factors
Contributing to Injury

Sexual assault
Sting/bite
Stroke/CVA
Syncope
Trauma
Other

None

Other
Factors

None

If an illness, not an
injury, skip G2 and
go to H3

Check all applicable boxes

Hispanic or Latino
Non Hispanic or Latino

34
35
36
37
38
00

Hypovolemia
Inhalation injury
Obvious death
OD/poisoning
Pregnancy/OB
Respiratory arrest
Respiratory distress
Seizure

Asleep
Unconscious
Possibly impaired by alcohol
Possibly impaired by drug
Possibly mentally disabled
Physically disabled
Physically restrained
Unattended person

1
2
3
4
5
6
7
8

Ethnicity

List up to five body sites

26
27
28
29
30
31
32
33

White
Black, African American
Am. Indian, Alaska Native
Asian
Native Hawaiian, Other
Pacific Islander
Other, multiracial
Undetermined

Body Site of Injury

Hour/Min

Time of Patient Transfer

Chest pain
Diabetic symptom
Do not resuscitate
Electrocution
General illness
Hemorrhaging/bleeding
Hyperthermia
Hypothermia

1
2

Year

Time Arrived at Patient

Race
1
2
3
4
5
0
U

Year

Gender

Month

Date/Time

EMS

Change

Exposure

Check one box only

18
19
20
21
22
23
24
25

Abdominal pain
Airway obstruction
Allergic reaction
Altered LOC
Behavioral/psych
Burns
Cardiac arrest
Cardiac dysrhythmia
Age or Date of Birth

Incident Number

Check if same date
as Alarm date

Use a separate form for each patient

NFIRS–6

Delete

Incident Date

State

Number of Patients

1
2
3

Injury Type

Accidental
Self-inflicted
Inflicted, not self

List one injury type for each body site listed under H1

Cause of
Illness/Injury

Cause of illness/injury

I
01
02
03
04
05
06
07
08
09
10
11
12
13

L1
1
2
3
4
0
N

Procedures Used

Check all applicable boxes

L2
1
2
3
4
0

14
15
16
17
18
19
20
21
22
23
24
00

No treatment

Highest Level of Care
Provided On Scene
First Responder
EMT-B (Basic)
EMT-I (Intermediate)
EMT-P (Paramedic)
Other provider

None

Safety
Equipment

6-21

Pre-arrival arrest?

If pre-arrival arrest, was it:

Safety/seat belts
Child safety seat
Airbag
Helmet
Protective clothing
Flotation device
Other
Undetermined

Improved
Remained same
Worsened

Check if:

1
2

Cardiac Arrest

Check all applicable boxes

Used or deployed by patient.
Check all applicable boxes.

Patient Status

1
2
3

None

Pulse on transfer
No pulse on transfer

Witnessed?

Bystander CPR?
Post-arrival arrest?

Initial Arrest Rhythm
1
0
U

N
1
2
3
4
0

V-Fib/V-Tach
Other
Undetermined

EMS
Disposition

Not transported

FD transport to ECF
Non-FD transport
Non-FD trans/FD attend
Non-emergency transfer
Other
NFIRS–6 Revision 01/01/04

NFIRS 5.0 Self-Study Program

Emergency Medical Services (EMS) Module Test
1. The EMS Module is

(a) intended to be a comprehensive EMS patient care report.

(b) not intended to replace State or local EMS patient care reporting.

(d) intended to include responding fire suppression units but not fire department EMS units.

2. The EMS Module replaces the Civilian Fire Casualty Module to document a civilian injured as a
result of a fire.

(a) True.

(b) False.

3. To determine the actual time the fire department spent with the patient, which two data elements
are needed?

(a) Arrival time.

(b) Time Arrived at Patient.

(d) Last Unit Clear Time.

4. Which two data elements enable EMS planners to identify the types of injuries experienced by
EMS patients?

(a) Human Factors and Other Factors.

(b) Initial Level of Provider and Highest Level of Care Provided on Scene.

(d) Primary Area of Body Injured and Human Factors Contributing to Injury.

5. To determine what was done to assess or treat the patient, use the following data element.

(a) Provider Impression/Assessment.

(b) Human Factors.

(d) Highest Level of Care Provided on Scene.

6-22

File Type	application/pdf
File Modified	2008-02-12
File Created	2008-02-12