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A
Location Type
Station
Incident Number
Exposure
NFIRS–1
Number/Milepost
Prefix
Apt./Suite/Room
City
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.
Census Tract
-
Street or Highway
Street Type
Suffix
State
ZIP Code
Cross Street, Directions or National Grid, as applicable
Incident Type
E1
Incident Type
D
Delete
Incident Date
State
Street address
Intersection
In front of
Rear of
Adjacent to
Directions
US National Grid
C
YYYY
Change
FDID
B
DD
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
E2
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
G1
Resources
Primary Action Taken (1)
G2
Apparatus
Personnel
Suppression
Additional Action Taken (2)
Other
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.
H1
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
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
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
F
E3
Arrival
Property
$
,
,
Contents
$
,
,
H3
Hazardous Materials Release
1
2
3
4
5
6
7
8
0
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
None
(Please complete the HazMat form.)
I
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
J
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
Person/Entity Involved
K1
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
MI
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
K2
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
MI
Prefix
Post Office Box
State
Area Code
Last Name
Suffix
Street or Highway
Apt./Suite/Room
Phone Number
Street Type
Suffix
City
ZIP Code
Remarks:
L
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.
M
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
MM
A
FDID
B
DD
YYYY
Incident Date
State
Station
Property Details
B1
C
Not Residential
Estimated number of residential living units in
building of origin whether or not all units
became involved
B2
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
None
,
Less than one acre
Acres burned (outside fires)
On-site material (3)
D
Ignition
E1
Cause of Ignition
Skip to
Section G
Check box if this is an exposure report.
E3
Human Factors
Contributing to Ignition
Check all applicable boxes
D1
Area of fire origin
D2
Heat source
D3
Item first ignited
1
Check box if fire spread was
confined to object of origin.
1
2
3
4
5
U
Intentional
Unintentional
Failure of equipment or heat source
Act of nature
Cause under investigation
Cause undetermined after investigation
E2
Factors Contributing to Ignition
3
4
5
None
6
Required only if item first
ignited code is 00 or <70
1
Factor contributing to ignition (2)
Equipment Involved in Ignition
None
Age was a factor
Estimated age of
person involved
Factor contributing to ignition (1)
Type of material first ignited
F2
None
Asleep
Possibly impaired by
alcohol or drugs
Unattended person
Possibly mentally disabled
Physically disabled
Multiple persons involved
1
2
7
D4
F1
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
Number of buildings involved
B3
NFIRS–2
Delete
Equipment Power Source
G
2
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
F3
Brand
1
Portable
2
Stationary
Fire suppression factor (1)
Fire suppression factor (2)
Model
Serial #
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
H1
Equipment Portability
Mobile Property Involved
None
H2
Fire suppression factor (3)
Mobile Property Type and Make
Local Use
Pre-Fire Plan Available
1
Not involved in ignition, but burned
2
Involved in ignition, but did not burn
3
Involved in ignition and burned
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
Structure Type
I1
If fire was in an enclosed building or a
portable/mobile structure, complete the
rest of this form.
1
2
3
4
5
6
7
8
0
Enclosed building
Portable/mobile structure
Open structure
Air-supported structure
Tent
Open platform (e.g., piers)
Underground structure (work areas)
Connective structure (e.g., fences)
Other type of structure
Fire Origin
J1
I2
Building Status
1
2
3
4
5
6
7
0
U
Under construction
Occupied & operating
Idle, not routinely used
Under major renovation
Vacant and secured
Vacant and unsecured
Being demolished
Other
Undetermined
J3
Number of stories w/significant damage
(25 to 49% flame damage)
N
None Present
1
Present
U
Undetermined
Detector Type
1
2
3
4
5
0
U
Smoke
Heat
Combination smoke and heat
Sprinkler, water flow detection
More than one type present
Other
Undetermined
M1
1
2
3
4
5
6
7
0
U
Wet-pipe sprinkler
Dry-pipe sprinkler
Other sprinkler system
Dry chemical system
Foam system
Halogen-type system
Carbon dioxide (CO2) system
Other special hazard system
Undetermined
Type of Material Contributing Most
to Flame Spread
Check if no flame spread OR if
same as Material First Ignited (Block D4,
Fire Module) OR if unable to determine.
Skip to
Section L
K1
K2
Number of stories w/extreme damage
(75 to 100% flame damage)
Detector Power Supply
0
U
L4
Detector Operation
1
Fire too small to activate
2
Operated
Complete
Block L5
3
Failed to operate
Complete
Block L6
U
Undetermined
M3
Type of material contributing
most to flame spread
L5
Battery only
Hardwire only
Plug-in
Hardwire with battery
Plug-in with battery
Mechanical
Multiple detectors & power
supplies
Other
Undetermined
1
2
3
4
5
6
7
Type of Automatic Extinguishing System
Required if fire was within designed range of AES
Width in feet
Item contributing most to flame spread
Presence of Automatic Extinguishing System
None Present
N
Present
1
Complete rest of
Section M
2
Partial System Present
U
Undetermined
M2
K
,
BY
Length in feet
Number of stories w/heavy damage
(50 to 74% flame damage)
L3
Skip to
Section M
,
,
Total square feet
,
Total number of stories
below grade
Fire Spread
(In area of the fire)
NFIRS–3
Structure
Fire
OR
Number of stories w/minor damage
(1 to 24% flame damage)
Presence of Detectors
L2
Total number of stories at or
above grade
Story of
fire origin
Confined to room of origin
Confined to floor of origin
Confined to building of origin
Beyond building of origin
L1
Main Floor Size
I4
Count the roof as part of the
highest story.
Count the roof as part of the highest story.
If fire spread was confined to object of origin,
do not check a box (Ref. Block D3, Fire Module).
2
3
4
5
Building
Height
Number of Stories Damaged by Flame
Below grade
J2
I3
1
2
3
4
U
L6
Detector Effectiveness
Required if detector operated.
Alerted occupants, occupants responded
Alerted occupants, occupants failed
to respond
There were no occupants
Failed to alert occupants
Undetermined
Detector Failure Reason
Required if detector failed to operate
1
2
3
4
5
6
0
U
Power failure, shutoff, or disconnect
Improper installation or placement
Defective
Lack of maintenance, includes
not cleaning
Battery missing or disconnected
Battery discharged or dead
Other
Undetermined
Operation of Automatic
Extinguishing System
M5
Required if fire was within designed range
Operated/effective (go to M4)
Operated/not effective (go to M4)
Fire too small to activate
Failed to operate (go to M5)
Other
Undetermined
1
2
3
4
0
U
M4
Number of Sprinkler
Heads Operating
Required if system operated
Required only if item
contributing code is 00 or <70.
Reason for Automatic
Extinguishing System Failure
Required if system failed or not effective
1
2
3
4
5
6
7
8
0
U
System shut off
Not enough agent discharged
Agent discharged but did not
reach fire
Wrong type of system
Fire not in area protected
System components damaged
Lack of maintenance
Manual intervention
Other
Undetermined
Number of sprinkler heads operating
NFIRS–3
Revision 01/01/06
MM
A
DD
Delete
FDID
State
Incident Date
Incident Number
Station
Gender
1
Male
Injured Person
B
First Name
MI
Age or Date of Birth
D
Months (for infants)
Age
E1
Date of Birth
Day
White
Black, African American
Am. Indian, Alaska Native
Asian
Native Hawaiian, Other
Pacific Islander
0
U
Other, multiracial
Undetermined
1
0
Cause of Injury
1
Exposed to fire products including flame
heat, smoke, and gas
Exposed to toxic fumes other than smoke
Jumped in escape attempt
Fell, slipped, or tripped
Caught or trapped
Structural collapse
Struck by or contact with object
Overexertion or strain
Multiple causes
Other
Undetermined
1
2
3
4
5
6
7
8
0
U
Escaping
Rescue attempt
Fire control
Return to fire before control
Return to fire after control
Sleeping
Unable to act
Irrational act
Other
Undetermined
G
Female
Affiliation
1
2
3
0
J
M1
Midnight is 0000.
Date and Time of Injury
Time of Injury
Month
Day
Year
Human Factors
Contributing to Injury
Hour
None
K
Severity
Minor
Moderate
Severe
Life threatening
Death
Undetermined
1
2
3
4
5
U
Minute
Factors Contributing
to Injury
None
Enter up to three contributing factors
Check all applicable boxes
1
2
3
4
5
6
7
8
Asleep
Unconscious
Possibly impaired by alcohol
Possibly impaired by other drug
Possibly mentally disabled
Physically disabled
Physically restrained
Unattended person
Location at Time of Incident
1
2
3
4
0
U
Casualty Number
H
Civilian
EMS, not fire department
Police
Other
Date of Injury
Hispanic or Latino
Non Hispanic or Latino
I
Activity When Injured
F
Casualty
Number
C
Ethnicity
Year
L
2
Change
Suffix
1
2
3
4
5
E2
Month
Exposure
Last Name
Race
OR
2
3
4
5
6
7
8
9
0
U
NFIRS–4
Civilian Fire
Casualty
YYYY
In area of origin and not involved
Not in area of origin and not involved
Not in area of origin, but involved
In area of origin and involved
Other location
Undetermined
M2
General Location at Time of Injury
1
2
3
U
In area of fire origin
In building, but not in area
Outside, but not in area
Undetermined
Skip to
Section N
M3
Contributing factor (1)
Contributing factor (2)
Contributing factor (3)
Story at Start of Incident
Complete ONLY if injury occurred INSIDE
Story at start of incident
M4
Below grade
Story Where Injury Occurred
Story where injury occurred, if
different from M3
M5
Below grade
Specific Location at Time of Injury
Complete ONLY if casualty NOT in area of origin
Skip to
Block M5
Specific location at time of injury
Primary Apparent Symptom
N
01
11
12
21
33
96
98
Smoke only, asphyxiation
Burns and smoke inhalation
Burns only
Cut, laceration
Strain or sprain
Shock
Pain only
Look up a code only if the symptom is NOT found above
Primary apparent symptom
O
Primary Area of Body Injured
P
Disposition
Transported to emergency care facility
1
2
3
4
5
6
7
8
9
Head
Neck and shoulder
Thorax
Abdomen
Spine
Upper extremities
Lower extremities
Internal
Multiple body parts
Remarks
Local option
NFIRS–4
Revision 01/01/04
MM
A
NFIRS–5
YYYY
Delete
FDID
B
DD
Incident Date
State
Station
Incident Number
Injured Person
1
2
Identification Number
Male
Female
Exposure
Change
Career
Volunteer
1
2
C
Fire Service
Casualty
Casualty Number
Casualty Number
First Name
D
Last Name
MI
Suffix
Age or Date of Birth
Age
E
Midnight is 0000.
Date and Time of Injury
Date of Injury
Date of Birth
Time of Injury
OR
In years
G1
1
2
3
4
5
6
7
8
0
H1
Month
Usual Assignment
Suppression
EMS
Prevention
Training
Maintenance
Communications
Administration
Fire investigation
Other
Day
Month
1
2
4
Rested
Fatigued
Ill or injured
Year
Hour
0
U
G4
Other
Undetermined
Report only, including exposure
First aid only
Treated by physician (no lost time)
Moderate (lost time)
Severe (lost time)
Life threatening (lost time)
Death
Primary Apparent Symptom
I1
Minute
Number of prior responses
during past 24 hours
Taken To
1
4
5
6
7
0
Severity
1
2
3
4
5
6
7
Not transported
Hospital
Doctor’s office
Morgue/funeral home
Residence
Station or quarters
Other
Activity at Time of Injury
G5
Activity at time of injury
Cause of Firefighter Injury
I3
Object Involved
in Injury
None
Cause of injury
Primary apparent symptom
H2
Day
Physical Condition Just Prior to Injury
G2
G3
Year
Responses
F
None
Primary Part of Body Injured
I2
Factor Contributing to Injury
None
Object involved in injury
Contributing factor
Primary injured body part
J1
Where Injury Occurred
1
2
3
4
5
6
7
8
9
0
U
En route to FD location
At FD location
En route to incident scene
En route to medical facility
At scene in structure
At scene outside
At medical facility
Returning from incident
Returning from med facility
Other
Undetermined
J2
Story Where Injury Occurred
1
Check this box and enter the story if the
injury occurred inside or on a structure
Story of injury
2
Injury occurred outside
Below grade
J3
65
64
63
61
54
53
49
45
36
35
34
33
32
31
28
27
26
25
24
23
22
Specific Location Where
Injury Occurred
In aircraft
In boat, ship, or barge
Complete
Block J4
In rail vehicle
In motor vehicle
In sewer
In tunnel
In structure
In attic
00
Other
In water
UU
Undetermined
In well
In ravine
In quarry or mine
In ditch or trench
In open pit
On steep grade
On fire escape/outside stairs
On vertical surface or ledge
On ground ladder
On aerial ladder or in basket
On roof
Outside at grade
J4
Vehicle Type
1
2
3
4
Suppression vehicle
EMS vehicle
Other FD vehicle
Non-FD vehicle
Complete ONLY if
Specific Location code
is >60
Remarks
If protective equipment failed and
was a factor in this injury, please
complete the other side of this
form.
NFIRS–5 Revision 01/01/05
K1
K2
Did protective equipment fail and contribute to the injury?
Yes
Y
Please complete the remainder of this form ONLY if you answer YES.
No
N
Protective Equipment Item
K3
Head or Face Protection
Coat, Shirt, or Trousers
11
12
13
14
15
16
17
10
21
22
23
24
25
26
27
28
20
NFIRS–5
Equipment
Sequence
Number
Fire Service
Casualty
Protective Equipment Problem
Check one box to indicate the main problem that occurred.
11
Burned
12
Melted
21
Fractured, cracked or broken
22
Punctured
23
Scratched
24
Knocked off
25
Cut or ripped
31
Trapped steam or hazardous gas
32
Insufficient insulation
33
Object fell in or onto equipment item
41
Failed under impact
42
Face piece or hose detached
43
Exhalation valve inoperative or damaged
44
Harness detached or separated
45
Regulator failed to operate
46
Regulator damaged by contact
47
Problem with admissions valve
48
Alarm failed to operate
49
Alarm damaged by contact
51
Supply cylinder or valve failed to operate
52
Supply cylinder/valve damaged by contact
Special Equipment
53
Supply cylinder—insufficient air/oxygen
61
62
63
64
65
66
67
68
69
71
72
73
74
75
76
77
78
79
70
00
94
Did not fit properly
95
Not properly serviced or stored prior to use
96
Not used for designed purpose
97
Not used as recommended by manufacturer
00
Other equipment problem
UU
Undetermined
Helmet
Full face protector
Partial face protector
Goggles/eye protection
Hood
Ear protector
Neck protector
Other
Protective coat
Protective trousers
Uniform shirt
Uniform T-shirt
Uniform trousers
Uniform coat or jacket
Coveralls
Apron or gown
Other
Boots or Shoes
31
32
33
34
35
36
37
38
30
Knee length boots with steel baseplate and steel toes
Knee length boots with steel toes only
3/4 length boots with steel baseplate and steel toes
3/4 length boots with steel toes only
Boots without steel baseplate and steel toes
Safety shoes with steel baseplate and steel toes
Safety shoes with steel toes only
Non-safety shoes
Other
Respiratory Protection
41
42
43
44
45
46
40
SCBA (demand) open circuit
SCBA (positive pressure) open circuit
SCBA closed circuit
Not self-contained
Cartridge respirator
Dust or particle mask
Other
Hand Protection
51
52
53
54
55
50
Firefighter gloves with wristlets
Firefighter gloves without wristlets
Work gloves
HazMat gloves
Medical gloves
Other
Proximity suit for entry
Proximity suit for non-entry
Totally encapsulated, reusable chemical suit
Totally encapsulated, disposable chemical suit
Partially encapsulated, reusable chemical suit
Partially encapsulated, disposable chemical suit
Flash protection suit
Flight or jump suit
Brush suit
Exposure suit
Self-contained underwater breathing apparatus (SCUBA)
Life preserver
Life belt or ladder belt
Personal alert safety system (PASS) Was the failure of more
than one item of protective
Radio distress device
equipment a factor in the
Personal lighting
injury? If so, complete an
Fire shelter or tent
additional page of this
Vehicle safety belt
form for each piece of
failed equipment.
Special equipment, other
Protective equipment, other
K4
Equipment Manufacturer, Model and Serial
Number
Manufacturer
Model
Serial Number
NFIRS–5
Revision 05/01/03
MM
A
FDID
YYYY
Station
Patient Number
Provider Impression/Assessment
10
11
12
13
14
15
16
17
E1
F1
Months (for infants)
Age
Month
E2
1
H1
OR
Day
Male
F2
2
Female
Day
None/no patient or refused treatment
White
Black, African American
Am. Indian, Alaska Native
Asian
Native Hawaiian, Other
Pacific Islander
Other, multiracial
Undetermined
Ethnicity
Hispanic or Latino
Non Hispanic or Latino
Body Site of Injury
H2
List up to five body sites
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
D
C
NFIRS–6
Delete
Incident Date
State
Number of Patients
B
DD
26
27
28
29
30
31
32
33
34
35
36
37
38
00
Hypovolemia
Inhalation injury
Obvious death
OD/poisoning
Pregnancy/OB
Respiratory arrest
Respiratory distress
Seizure
G1
Human Factors
Contributing to Injury
Sexual assault
Sting/bite
Stroke/CVA
Syncope
Trauma
Other
None
G2
None
If an illness, not an
injury, skip G2 and
go to H3
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
Other
Factors
1
2
3
Injury Type
Accidental
Self-inflicted
Inflicted, not self
H3
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
J
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
Highest Level of Care
Provided On Scene
First Responder
EMT-B (Basic)
EMT-I (Intermediate)
EMT-P (Paramedic)
Other provider
None
M
Safety
Equipment
Pre-arrival arrest?
1
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
K
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
2
1
Witnessed?
2
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
MM
A
FDID
DD
YYYY
Delete
Incident Date
State
Station
Incident Number
HazMat ID
B
DOT Hazard
Classification
UN Number
Container
Type
C1
None
C2
Estimated Container Capacity
D1
More hazardous
materials? Use
additional sheets.
Complete the remainder
of this form only for the
first hazardous material
involved in this incident.
C3
Units: Capacity
VOLUME
Ounces
Gallons
Barrels: 42 gal.
Liters
Cubic feet
Cubic meters
11
12
13
14
15
16
Population Density
F2
1
2
3
Urban
Suburban
Rural
Check all applicable boxes
Below grade
1
Inside/on structure
Story of release
2
Outside of structure
G1
Area Affected
1
2
3
D2
WEIGHT
Ounces
Pounds
Grams
Kilograms
G2
G3
Area Evacuated
Square feet
G4
,
Estimated Number of
People Evacuated
1
2
3
4
5
U
Intentional
Unintentional release
Container/containment failure
Act of nature
Cause under investigation
Cause undetermined after
investigation
K
Estimated Number of
Buildings Evacuated
None
Factors Contributing to Release
L
Enter up to three contributing factors
M
Equipment Involved
in Release
Equipment involved in release
Brand
Enter up to three actions taken
Additional action taken (2)
If fire or explosion is involved with a
release, which occurred first?
I
1
2
Ignition
Release
Factor contributing to release (3)
Factor or impediment (3)
None
Release
O
1
2
3
4
5
6
7
8
Mobile property type
Mobile property make
Model
Year
Serial #
License plate number
Year
DOT number/ ICC number
State
Undetermined
None
Enter up to three factors or impediments that affected the
mitigation of the incident
Factor or impediment (2)
Mobile Property Involved in
U
Factors Affecting Mitigation
Factor contributing to release (2)
Model
Released into
HazMat Actions Taken
H
Factor or impediment (1)
N
Released Into
Enter Code
Factor contributing to release (1)
None
E2
Additional action taken (3)
,
Enter measurement
WEIGHT
Ounces
Pounds
Grams
Kilograms
MICRO UNITS
21
22
23
24
Solid
Liquid
Gas
Undetermined
Primary action taken (1)
,
Square miles
Cause of Release
None
Enter
measurement
Square miles
Blocks
Check one box
1
2
3
U
,
Blocks
Square feet
J
Units: Released
VOLUME
Ounces
Gallons
Barrels: 42 gal.
Liters
Cubic feet
Cubic meters
11
12
13
14
MICRO UNITS 15
Enter Code 16
1
2
3
Released From
F1
,
,
Amount released: by volume or weight
Check one box
21
22
23
24
HazMat
State
E1 Physical
When Released
Estimated Amount Released
,
Capacity: by volume or weight
Container Type
Change
Haz No.
Chemical
Name
CAS Registration Number
,
Exposure
NFIRS–7
P
HazMat Disposition
Completed by fire service only
Completed w/fire service present
Released to local agency
Released to county agency
Released to state agency
Released to federal agency
Released to private agency
Released to property owner or
manager
HazMat Civilian Casualties
Deaths
Injuries
NFIRS–7
Revision 01/01/06
A
MM
FDID
DD
Incident Date
State
Station
Alternate Location Specification
B
•
•
Longitude
OR
North
South
•
Township
East
West
Exposure
Misuse of fire
Other
Undetermined
8
Natural source
0
Equipment
U
Smoking
Open/outdoor fire
Debris/vegetation burn
Structure (exposure)
Incendiary
D2
Human Factors Contributing
to Ignition
Subsection
1
2
3
4
5
6
7
Area Type
C
1
2
3
4
H
Meridian
Rural, farms >50 acres
Urban (heavily populated)
Rural/urban or suburban
Urban-wildland interface area
Weather Information
I2
F°
Wind Speed (mph)
Air Temperature
Relative Humidity
Fuel Moisture
U
#2
E
Heat Source
F
Mobile Property Type
None
Equipment Involved
in Ignition
G
None
Primary Crops Burned
I4
Identify up to 3 crops if any crops were burned
Number of Buildings Threatened
None
Crop 1
Crop 2
I3
Total Acres Burned
,
Fire Danger Rating
K
Indicate the percent of the total acres burned for each ownership type then check the ONE box to identify the property ownership at the origin of the fire. If the ownership at origin is Federal,
enter the Federal Agency Code.
Ownership
None
Number of buildings that were threatened by
Wildland fire but were not involved
Check if
negative
Property Management
J
None
%
%
Fire Suppression Factors
D4
None
Number of Buildings Ignited
Wind Direction
Weather Type
#2
#3
Number of buildings that were
ignited in Wildland fire
NFDRS Weather Station ID
None
#1
Asleep
Possibly impaired by alcohol or drugs
Unattended person
Possibly mentally disabled
Physically disabled
Multiple persons involved
Age was a factor
I1
#1
Enter
up to
three
factors
Check as many boxes as are applicable.
Section
NFIRS–8
Wildland
Fire
Factors Contributing
to Ignition
D3
1
2
3
4
5
6
7
Range
Change
Incident Number
Wildland Fire Cause
D1
Enter Latitude/Longitude OR Township/Range/Section/Subsection
Meridian if Section B on the Basic Module is not completed
Latitude
Delete
YYYY
•
,
NFDRS Fuel Model at Origin
Crop 3
M
Type of Right-of-Way
None
Required if less than 100 feet
Enter the code and the descriptor corresponding
to the NFDRS Fuel Model at Origin
Feet
Horizontal distance
from right-of-way
Type of right-of-way
% Total Acres Burned
Undetermined
L1
Person Responsible for Fire
1
2
3
Identified person caused fire
Unidentified person caused fire
Fire not caused by person
N
Fire Behavior
%
Private
These optional descriptors refer to observations
made at the point of initial attack
If person identified, complete the rest of Section L
1
2
Tax paying
Non-tax paying
Feet
%
%
L2
Gender of Person Involved
1
2
Public
3
4
5
6
City, town, village, local
County or parish
State or province
Federal
7
8
0
Foreign
Military
Other
%
%
L3
Male
Female
Relative position on slope
Age or Date of Birth
Age in Years
Aspect
Date of Birth
OR
%
Month
Day
Year
%
Federal Agency Code
%
Feet
Flame length
L4
Activity of Person Involved
%
%
Elevation
Chains per Hour
Rate of spread
Activity of Person Involved
NFIRS–8 Revision 01/01/04
A
MM
DD
NFIRS–9
Delete
YYYY
Change
FDID
B
Incident Date
State
Apparatus or
Resources
Dates and Times
ID
Type
2
ID
Type
3
ID
Type
4
ID
Type
5
ID
Type
6
ID
Type
7
ID
Type
8
ID
Type
9
ID
Type
Midnight is 0000
Check if same date as Alarm date on
the Basic Module (Block E1)
Use codes listed below
1
Station
Month
Day
Year
Hour/Min
Incident Number
Sent
X
Number
of
People
Exposure
Apparatus Use
Check ONE box for each
apparatus to indicate its main
use at the incident.
Dispatch
Dispatch
Suppression
EMS
Other
Arrival
Clear
Dispatch
Suppression
EMS
Other
Arrival
Clear
Dispatch
Suppression
EMS
Other
Arrival
Clear
Dispatch
Suppression
EMS
Other
Arrival
Clear
Dispatch
Suppression
EMS
Other
Arrival
Clear
Dispatch
Suppression
EMS
Other
Arrival
Clear
Dispatch
Suppression
EMS
Other
Arrival
Clear
Dispatch
Suppression
EMS
Other
Arrival
Clear
Ground Fire Suppression
11 Engine
12 Truck or aerial
13 Quint
14 Tanker and pumper combination
16 Brush truck
17 ARFF (aircraft rescue and firefighting)
10 Ground fire suppression, other
Heavy Ground Equipment
21 Dozer or plow
22 Tractor
24 Tanker or tender
20 Heavy ground equipment, other
Actions Taken
List up to 4 actions for each
apparatus.
Suppression
EMS
Other
Arrival
Clear
Apparatus or Resource Type
Apparatus or
Resources
Aircraft
41 Aircraft: fixed-wing tanker
42 Helitanker
43 Helicopter
40 Aircraft, other
Marine Equipment
51 Fire boat with pump
52 Boat, no pump
50 Marine equipment, other
Support Equipment
61 Breathing apparatus support
62 Light and air unit
60 Support apparatus, other
Medical and Rescue
71 Rescue unit
72 Urban search and rescue unit
73 High-angle rescue unit
75 BLS unit
76 ALS unit
70 Medical and rescue unit, other
More apparatus?
Use additional
sheets.
Other
91 Mobile command post
92 Chief officer car
93 HazMat unit
94 Type I hand crew
95 Type II hand crew
99 Privately owned vehicle
00 Other apparatus/resources
NN None
UU Undetermined
NFIRS–9
Revision 01/01/04
MM
A
FDID
B
Apparatus or
Resources
DD
Incident Date
State
Station
Dates and Times
ID
Type
ID
Type
ID
Type
Personnel
ID
Incident Number
Sent
X
Hour/Min
Exposure
Number
of
People
Sent
Name
Rank or
Grade
Attend
X
Action
Taken
Sent
Dispatch
Arrival
Rank or
Grade
Attend
X
Action
Taken
Sent
Dispatch
Arrival
Rank or
Grade
Attend
X
Personnel
Apparatus Use
Actions Taken
Check ONE box for each
apparatus to indicate its main
use at the incident.
List up to 4 actions for
each apparatus and
each personnel.
Action
Taken
Action
Taken
Action
Taken
Action
Taken
Action
Taken
Action
Taken
Suppression
EMS
Other
Clear
Name
NFIRS–10
Change
Suppression
EMS
Other
Clear
Name
Delete
Suppression
EMS
Other
Clear
Personnel
ID
3
Year
Dispatch
Arrival
Personnel
ID
2
Midnight is 0000
Check if same date as Alarm date on
the Basic Module (Block E1)
Month Day
1
YYYY
Action
Taken
Action
Taken
Action
Taken
NFIRS–10
Action
Taken
Revision 01/01/04
MM
A
FDID
State
YYYY
Station
Incident Number
Change
Exposure
None
Street address
Their case number
Agency name
City
Their ORI
Agency phone number
State
Case Status
Investigation open
1
Investigation closed
2
Investigation inactive
3
C
11
12
13
14
15
21
Extortion
Labor unrest
Insurance fraud
Intimidation
Void contract/lease
Personal
22
23
24
31
32
41
Hate crime
Institutional
Societal
Protest
Civil unrest
Fireplay/curiosity
None
Check up to three factors
1
2
3
4
5
6
7
8
0
U
G1
Terrorist group
Gang
Anti-government group
Outlaw motorcycle organization
Organized crime
Racial/ethnic hate group
Religious hate group
Sexual preference hate group
Other group
Unknown
Entry Method
D
Availability of Material First Ignited
1
2
U
Transported to scene
Available at scene
Unknown
42
43
44
45
51
52
53
H
Incendiary Devices
11
12
13
Bottle (glass)
Bottle (plastic)
Jug
11
12
13
14
15
16
Wick or fuse
Candle
Cigarette and matchbook
Electronic component
Mechanical device
Remote control
Burglary
Homicide concealment
Burglary concealment
Auto theft concealment
Destroy records/evidence
Other suspected motivation
Unknown motivation
54
61
62
63
64
00
UU
Vanity/recognition
Thrills
Attention/sympathy
Sexual excitement
Homicide
Suicide
Domestic violence
No container
CONTAINER
Select one from each category
Extent of Fire Involvement on Arrival
No device
IGNITION/DELAY DEVICE
11
12
14
15
Box
Other Container
Unknown
Pressurized container 17
00
Can (not gas or fuel)
UU
Gasoline or fuel can
14
15
16
17
18
19
20
00
UU
Road flare/fuse
Chemical component
Trailer/streamer
Open flame source
Other delay device
Unknown
None
FUEL
Entry Method
G2
Their FDID
Their Federal Identifier (FID)
Check up to three factors
Apparent Group Involvement
F
ZIP code
Closed with arrest
Closed with exceptional
clearance
4
5
Suspected Motivation Factors
E
NFIRS–11
Arson
Delete
Incident Date
Agency Referred To
B
DD
Ordinary combustibles
Flammable gas
Ignitable liquid
Ignitable solid
16
17
00
UU
Pyrotechnic material
Explosive material
Other material
Unknown
Extent of Fire Involvement
I
Other Investigative Information
J
Property Ownership
K
Initial Observations
Check all that apply
Check all that apply
1
2
3
4
5
6
7
8
Code violations
Structure for sale
Structure vacant
Other crimes involved
Illicit drug activity
Change in insurance
Financial problem
Criminal/civil actions pending
1
2
3
4
5
6
7
0
Private
City, town, village, local
County or parish
State or province
Federal
Foreign
Military
Other
1
2
3
4
L
1
2
Windows ajar 5
Doors ajar
6
Doors locked 7
Doors unlocked 8
Fire department forced entry
Entry forced prior to FD arrival
Security system activated
Security system present
(not activated)
Laboratory Used
Local
State
3
4
ATF
FBI
Check all that apply
5
Other
Federal
None
6
Private
NFIRS–11 Revision 01/01/04
MM
A
FDID
State
DD
YYYY
Incident Date
M2
Complete this section
if the person involved in
the ignition of the fire
was a child or Juvenile
under the age of 18
Station
Age or Date of Birth
Incident Number
4
5
Day
Year
0
U
M1
Subject Number
Complete a separate Section M
form for each juvenile
M3
1
Gender
Male
M5
2
Female
Subject Number
M7
N
Motivation/Risk Factors
Check only one of codes 1–3
and then all others (4–9)
that apply
1
2
3
Mild curiosity about fire
Moderate curiosity about fire
Extreme curiosity about fire
4
5
6
7
8
9
0
U
Diagnosed (or suspected) ADD/ADHD
History of trouble outside school
History of stealing or shoplifting
History of physically assaulting others
History of fireplay or firesetting
Transiency
Other
Unknown
Remarks (local use)
M8
M6
White
Black, African American
American Indian, Alaska
Native
Asian
Native Hawaiian, Other
Pacific Islander
Other, multiracial
Undetermined
OR
Ethnicity
1
0
Change
Exposure
Race
M4
1
2
3
Age (in years)
Month
NFIRS–11
Delete
Hispanic or Latino
Non Hispanic or Latino
Juvenile
Firesetter
Family Type
1
Single parent
2
Foster parent(s)
3
Two-parent family
4
Extended family
N
No family unit
0
Other family type
U
Unknown
Disposition of Person Under 18
1
2
3
4
5
6
0
U
Handled within department
Released to parent/guardian
Referred to other authority
Referred to treatment/counseling program
Arrested, charged as adult
Referred to firesetter intervention program
Other
Unknown
MM
A
FDID
K1
State
DD
Incident Date
Station
Change
Supplemental
Number
MI
Prefix
Last Name
Suffix
Street or Highway
Apt./Suite/Room
Phone Number
Street Type
Suffix
City
ZIP Code
Person/Entity Involved
Area Code
Business Name (if applicable)
Local Option
Check this box if
same address as
incident location.
Then skip these
these duplicate
address lines.
Mr., Ms., Mrs.
First Name
Number
MI
Prefix
Post Office Box
State
Last Name
Suffix
Street or Highway
Apt./Suite/Room
Phone Number
Street Type
Suffix
City
ZIP Code
Person/Entity Involved
Business Name (if applicable)
Local Option
Check this box if
same address as
incident location.
Then skip these three
duplicate address
lines.
Mr., Ms., Mrs.
MI
Prefix
Number
State
Area Code
First Name
Post Office Box
Last Name
Suffix
Street or Highway
Apt./Suite/Room
Phone Number
Street Type
Suffix
City
ZIP Code
Person/Entity Involved
Area Code
Business Name (if applicable)
Local Option
Check this box if
same address as
incident location.
Then skip these three
duplicate address
lines.
Mr., Ms., Mrs.
First Name
Number
MI
Prefix
Post Office Box
State
K1
Exposure
Area Code
First Name
Mr., Ms., Mrs.
State
K1
Incident Number
Business Name (if applicable)
Local Option
Post Office Box
K1
NFIRS–1S
Delete
Person/Entity Involved
Check this box if
same address as
incident location.
Then skip these three
duplicate address
lines.
K1
YYYY
Last Name
Suffix
Street or Highway
Apt./Suite/Room
Phone Number
Street Type
Suffix
City
ZIP Code
Person/Entity Involved
Business Name (if applicable)
Area Code
Phone Number
Local Option
Check this box if
same address as
incident location.
Then skip these three
duplicate address
lines.
Mr., Ms., Mrs.
First Name
Number
Prefix
Post Office Box
State
MI
Street or Highway
Apt./Suite/Room
ZIP Code
Last Name
Suffix
Street Type
Suffix
City
NFIRS–1S
Revision 01/01/04
E3
Supplemental
Local Option
1
2
Special
Study ID#
Special
Study Value
Special
Study ID#
Special
Study Value
3
Special
Study ID#
Special
Study Value
Special
Study ID#
Special
Study Value
6
5
L
NFIRS–1S
Supplemental Special Studies
4
Special
Study ID#
Special
Study Value
Special
Study ID#
Special
Study Value
7
Special
Study ID#
Special
Study Value
Special
Study ID#
Special
Study Value
8
Remarks:
Local Option
NFIRS-1S
Revision 01/01/04
| File Type | application/pdf |
| File Title | Untitled Document |
| File Modified | 2006-01-03 |
| File Created | 2003-10-16 |