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pdfO.M.B. No. 1660-0058
Expires September 30, 2014
DEPARTMENT OF HOMELAND SECURITY
Federal Emergency Management Agency
REQUEST FOR FIRE MANAGEMENT ASSISTANCE DECLARATION
PAPERWORK BURDEN DISCLOSURE NOTICE
Public reporting burden for this data collection is estimated to average 1 hour per response. The burden estimate includes the time for
reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and submitting this form.
This collection of information is required to obtain or retain benefits. You are not required to respond to this collection of information unless a
valid OMB control number is displayed on this form. Send comments regarding the accuracy of the burden estimate and any suggestions for
reducing the burden to: Information Collections Management, Department of Homeland Security, Federal Emergency Management Agency,
500 C Street, SW., Room 7NE, Washington, DC 20472-3100, Paperwork Reduction Project (1660-0058) NOTE: Do not send your completed
form to this address.
1. STATE
2. DATE OF REQUEST
4. NAME OF GOVERNOR OR AUTHORIZED REPRESENTATIVE
PHONE NO. INCLUDING AREA CODE
b. Night
a. Day
5. AGENCY REPRESENTED
3. TIME OF REQUEST
ADDRESS (Street, City, Zip)
NOTE: In making this request, the Government agrees to abide by provisions contained in FEMA-State Agreement for Fire Management
Assistance under Section 420, PI 93-288 as amended. This request must be signed below by the Governor personally or by his authorized
representative, whom he has previously authorized to sign this request in the FEMA - State Agreement.
TITLE
6. SIGNATURE
DATE
I. EXISTING CONDITIONS
7.
EXISTENCE OF
HIGH
FIRE DANGER
CONDITIONS
a. TEMPERATURE
c. DIRECTION AND VELOCITY OF WIND
b. RELATIVE HUMIDITY
d. PREVAILING WEATHER CONDITIONS AND PREDICTIONS FOR NEXT 24 HOURS
8. NUMBER OF WILD FIRES
a. CONTROLLED
ACRES BURNED
b. UNCONTROLLED
ACRES BURNED
c. EXISTENCE OF OTHER FIRES NEARBY WHICH LIMITS THE COMMITMENT OF STATE FIRE FIGHTING
RESOURCES #
d. EXISTENCE OF OTHER FIRES NEARBY THAT MAY RESULT IN A
CONFLAGRATION #
9. INDICIES
10. BURN BANS
NATIONAL FIRE DANGER RATING
SYSTEM
OTHER (KBDI, SPI, HAINES, PALMER,
ETC.)
YES
NO
11. NATIONAL WATCHES
WARNINGS
YES
NO
YES
NO
II. FIRE SITUATION REPORT
12. TIME OF REPORT
13. NAME OF UNCONTROLLED FIRE
15. LOCATION OF UNCONTROLLED FIRE: (County)
14. DATE
16. ACRES BURNING:
a. FEDERAL
%
b. STATE
%
c. PRIVATE
%
17. MANPOWER AND RESOURCES COMMITTED (Attach separate sheet if necessary)
STATE:
LOCAL:
18. TYPE AND AMOUNT OF FEDERAL OR OTHER ASSETS & RESOURCES NEEDED: (FEMA does not order resources)
FEMA FORM 078-0-1 (08/14)
Page 1 of 2
O.M.B. No. 1660-0058
Expires September 30, 2014
DEPARTMENT OF HOMELAND SECURITY
Federal Emergency Management Agency
REQUEST FOR FIRE MANAGEMENT ASSISTANCE DECLARATION
III. CURRENT THREAT
19. THREAT TO LIFE:
a. PREPARATIONS MADE FOR EVACUATION? b. PERSONS EVACUATED:
YES
#
NO
20. NAME AND LOCATION OF COMMUNITY THREATENED
ADDITIONAL INFORMATION
TOWN
CITY
#
SUBDIVISION
21. CASUALTIES
22. THREAT TO PRIVATE PROPERTY (Dwellings)
1. CIVILIAN LOSS OF LIFE
1. NUMBER OF HOMES
2. CIVILIANS INJURED
a. % OF PRIMARY
3. FIRE FIGHTERS LOSS OF
LIFE
b. % OF SECONDARY
4. FIRE FIGHTERS INJURED
23. THREAT TO FACILITIES (Include number when applicable)
AMOUNT
TYPE
AMOUNT
BUILDINGS
RECREATION
ROADS & BRIDGES
EQUIPMENT
INFASTRUCTURE
BUSINESS
UTILITIES
OTHER
TYPE
ADDITIONAL INFORMATION
24. THREAT TO RESOURCES
WATERSHED
WILDLIFE (Type threatened, fur-bearing animals, big game, etc.)
IRRIGATION
ENVIRONMENTAL RESOURCES (bio-diverse areas, etc.)
FLOOD CONTROL
CULTURAL RESOURCES
FISHING STREAMS & SPAWNING SITES
ECONOMIC INJURY
ADDITIONAL INFORMATION
IV. STATE ASSESSMENT
25. EMERGENCY MANAGEMENT ASSESSMENT OF THE SITUATION
DATE
SIGNATURE
26. FORESTRY ASSESSMENT OF THE SITUATION
DATE
SIGNATURE
FOR FEMA REGIONAL USE ONLY
SIGNATURE
FEMA FORM 078-0-1 (08/14)
TITLE
DATE
Page 2 of 2
| File Type | application/pdf |
| File Title | FEMA Form |
| File Modified | 2014-08-27 |
| File Created | 2014-08-27 |