NFIRS Version 5.0 NFIRS Version 5.0 Modules (electronic)

MM

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