NFIRS Module 5 - Fire Service Casualty

National Fire Incident Reporting System (NFIRS) Version 5.0

NFIRS Module 5 - Fire Service Casualty

OMB: 1660-0069

⚠️ Notice: This form may be outdated.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

Document [pdf]

Download: pdf | pdf

NFIRS 5.0 Self-Study Program

Fire Service Casualty
Module: NFIRS-5

Objectives
After completing the Fire Service Casualty Module the student will be
able to:
1. Describe when the Fire Service Casualty Module is to be used.
2. Demonstrate how to complete the Fire Service Casualty Module, given
the scenario of a hypothetical incident.

5-1

Table of Contents
Pretest #5 - Fire Service Casualty Module. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5-3
Using the Fire Service Casualty Module. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5-4
Section A: FDID, Incident Number, Exposure. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5-4
Section B: Injured Person. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5-4
Section C: Casualty Number. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5-5
Section D: Age or Date of Birth. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5-5
Section E: Date and Time of Injury. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5-5
Section F: Responses. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5-5
Section G: Usual Assignment, Physical Condition Just Prior To Injury, Severity,
Taken To, Activity at Time of Injury . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5-6
Section H: Primary Apparent Symptom and Primary Area of Body Injured . . . . . . . . . . . . . . 5-7
Section I: Cause of Firefighter Injury, Factor Contributing to Injury, and
Object Involved in Injury. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5-7
Section J: Where Injury Occurred, Story Where Injury Occurred, Specific Location,
and Vehicle Type. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5-8
Section K: Contribution of Protective Equipment to Injury . . . . . . . . . . . . . . . . . . . . . . . . . . 5-9
SUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5-12
EXAMPLE: Highrise Fire. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5-13
EXERCISE SCENARIO 5-1: Fire Captain Injury on Scene of Fire . . . . . . . . . . . . . . . . . . . . . . 5-16
EXERCISE SCENARIO 5-2: Cary Street Fire. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5-21
Fire Service Casualty Module Test. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5-29

NFIRS 5.0 Self-Study Program

Pretest #5 - Fire Service Casualty Module
1. The Fire Service Casualty Module is used to report injuries, deaths, or exposures to fire service,
EMS, and other public safety personnel that occur in conjunction with any incident response.

(a) True.

(b) False.

2. A Basic Module must be completed if the Fire Service Casualty Module is completed.

(a) True.

(b) False.

3. The Fire Service Casualty Module is a required NFIRS Module.

(a) True.

(b) False.

4. The Fire Service Casualty Module should be completed if a firefighter is injured while exercising
at the fire station.

(a) True.

(b) False.

5. The Fire Service Casualty Module should be completed if a firefighter is injured while off-duty
away from the fire station.

(a) True.

(b) False.

5-3

NFIRS 5.0 Self-Study Program

Using the Fire Service Casualty Module

he Fire Service Casualty Module is used to report fire service personnel injuries, deaths, or exposures while on duty. This module is also used to collect information about protective equipment
that failed and contributed to the injury.
An exposure is defined as contact by fire service personnel with a toxic substance or harmful physical
or biological agent through any route of entry (e.g., inhalation, ingestion, skin absorption, or direct
contact). Exposures can be reported regardless of the presence of clinical signs and symptoms.
NOTE: An exposure fire is not the same as an exposure to fire service personnel.
Recording firefighter casualty information provides data on specific, perhaps correctable, hazards. It
also can indicate trends that can lead to future safety improvement efforts. Health and Safety Officers
find this information particularly useful when working to reduce risks at incidents.

Section A: FDID, Incident Number, Exposure
MM

NFIRS–5

YYYY
Delete

FDID

State

Incident Date

Station

Incident Number

Exposure

Change

Fire Service
Casualty

Injured Person
Casualty Number
Male
Career
1
1
The
of theNumber
Fire Module is drawn
from Section
A of theCBasic
Module. Use
B information in Section AIdentification
Female
Volunteer
2
2
the data in the Basic Module to help you supply the requested information. If you are using an autoCasualty Number
mated
system the data need
toLastbe
entered only once, then they will beSuffix
transferred automatically
into
First Name
Name
MI
other modules that use the data.

Age or Date of Birth
Age

In years

G1
1
2
3
4
5
6
7
8
0

E
Date of Birth

FDID

Month

Injured Person
Usual Assignment
B
G2

Date and Time of Injury

Date of Injury
YYYY

Midnight is 0000.

State
Day

Month

Day

Responses

Time of Injury

Section B: Injured Person
Incident Date
Year

Station
Year

Incident Number
Hour

Minute

Delete
Number of prior responses
Exposure
during past 24 hours Change

NFIRS–5

Fire Service
Casualty

Male
Career
1
Taken To
C Casualty Number
Not transported
Female
Volunteer
2
1
Hospital
0
Other
1
Rested
Suppression
4
Doctor’s office
Undetermined
U
2
Fatigued
Casualty Number
EMS First Name
5
Morgue/funeral
Last Name
Suffix home
Ill orMIinjured
4
Prevention
Residence
6
Training
Station or quarters
7
Severity
Midnight is 0000.
Responses
Maintenance
Age or DateG
of3Birth
Date and Time
ofOther
Injury
0
D
E
F
1
Report only, including exposure
Communications
2
First aid only
Date of Injury
Administration
Injury
Age
Date of Birth
Activity at TimeTime
of ofInjury
3
Treated by physician (no lost time)
G5
Fire investigation
OR4
Number of prior responses
Moderate (lost time)
Other
during past 24 hours
In years
Month
Day time) Year
Month
Day
Year
5
Severe
(lost
Hour
Minute
6
Life threatening (lost time)
Activity at time of injury
7
Death
Usual Assignment
Physical Condition Just Prior to Injury
Not transported
G1
G2
G4 Taken To
Physical Condition Just Prior to Injury
Identification Number

G
2 4

Section B is used to identify and classify the person injured or exposed using a variety of means.

Start completing Section B by entering an assigned identification number. While the individual’s
Social Security Number often is used for this purpose, this is not a recommended practice.

Next, check the appropriate boxes indicating male or female, and the casualty’s affiliation (career or
volunteer). Paid-per-call casualties should be considered volunteers when information for this sec1 Object
Hospital
tion isPrimary
entered.
Lastly,
enter the casualty’s
firstCause
andoflast
middle initial, and
any
suffix (i.e.,None
Jr.,
Apparent
Symptom
Firefighter
Injury
Involved
0name,
Other
1
1
Suppression
H1
I1 Rested
I34 in Doctor’s
office
Injury
Undetermined
U
2
Fatigued
Sr., or III) in2 the lines
EMS provided.
5
Morgue/funeral home
3
Prevention
4
Training
5
Primary Part
of Maintenance
Body Injured
6
Communications
7
Administration
Primary injured8body part Fire investigation
0
Other

Ill or injured

Residence
6
Cause of injury
Station or quarters
7
Severity
None
G3 1 I2 Factor Contributing to Injury
Other
0
None
H2
Report only, including exposure
2
First aid only
Object involved in injury
Activity at Time of Injury
3
Treated
by physician (no lost time)
G5
Contributing factor
4
Moderate (lost time)
5
Severe (lost time)
Specific Location
Where
6
Where Injury Occurred
Life
threatening (lost time) Vehicle Type Activity at time of injuryComplete ONLY if
J3 Injury Occurred
J4
J1
Specific Location code
7
Death
is >60
1
En route to FD location
1
Suppression vehicle
65
In aircraft
2
2
At FD location
EMS vehicle
64Symptom
In boat, ship, or barge
Complete Cause of Firefighter
Primary
Apparent
Injury
Object Involved
3
Other
FD vehicle
3
En route to incident
scene
Block J4
Primary apparent symptom

5-4

None

NFIRS 5.0 Self-Study Program
MM

YYYY

NFIRS–5

Section C: Casualty Number
Delete

Incident Date

Station

Incident Number

Male
Female

1
2

Identification Number

Exposure

Career
Volunteer

1
2

Fire Service
Casualty

Change

Casualty Number

Casualty Number
Last Name

Suffix
MM
DD
YYYY
Each casualty
is given a number.
The
numbers are
assigned
sequentially
starting with one (001), and
Midnight
is 0000.
Responses
Date and Time of Injury A
E
F
Incident Date
continuing based upon how manyFDIDfire serviceState
individuals
were injured orStation
killed atIncident
theNumber
incident, or Exposure
Date of Injury
Time of Injury
resulting from the incident.

ate of Birth

onth

Day

1
2
4

Rested
Fatigued
Ill or injured

Day

0
U

BHour

Year

1
2
A34
5
6
7

Identification Number

Not transported
MI

Hospital
Doctor’s office
Age or Date ofhome
Birth
Morgue/funeral
Residence
Age
Station
or quarters
Other
OR
In years

Identification Number

Month

Last Name

Cause of injury

Factor Contributing to Injury
Age or Date Iof
2 Birth

OR
In years

Month

Year

Month

Day

Year

Midnight is 0000.

Date and Time of Injury

Month

Day

Year

Hour

Minute

Number
during pa

NFIRS–5

1
4
5
6
7
0

None

Casualty Number

Suffix

2
First aid only
3
Treated by physician (no lost time)
Midnight is 0000.
Responses
4
Moderate (lost
F time)
5
Severe (lost time)
Time of Injury
6
Life threatening (lost time)
7
Death
Number of prior responses
Minute

Time of Injury

0
Other
1
Rested
Undetermined
U
2
Fatigued
Casualty
Number
Career
C
Ill or injured
4
Volunteer

Hour

Casua

Casualty

Fire Service
Physical
Condition
Prior to Injury
Exposure
not
both.
If the
ageChange
isJust
entered,
the numbers
are To
Casualty
G
2
G4 Taken

Object involved in injury
Date of Injury

Day

Year

Delete

1
Suppression
Male
1
2
EMS 1
Female
2
2
3
Prevention
Object Involved
4
Training
I3 in Injury
5
Maintenance
G3
6
Communications
7
Administration
8
Fire investigation
None Date and Time of Injury
0 E Other

Date of Birth
Contributing factor

Specific Location Where
Injury Occurred
Usual Assignment

Day

Suffix

Severity
Section E: Date and Time
of Injury
1
Report only, including exposure

None

Age

Career
Volunteer

1
2

Date of Injury

Date of Birth

Activity at Time of Injury
G5YYYY

Cause of Firefighter Injury
MI

Male
Female

Last Name

Station
Incident Number
Enter either the casualty’s age
dateAssignment
of birth,
but
G1orUsual
assumed to represent years.Activity at time of injury

First Name

1
2

Minute

First Name

1
4
5D
6
7
0

Other
Undetermined

Report only, including exposure
First aid only
MM time)
DD
Treated by physician (no lost
Moderate (lost time)
Incident Date
FDID
State
Severe (lost time)
Life threatening (lost time)
Death
Injured Person

Number of prior responses

Injured Person
during past 24 hours

Section
D: Age or Date of Birth
Taken To

Severity

ured

Month

Physical Condition Just Prior to Injury

Year

Delete

Change

Not

Hospital
Doctor’s office
Morgue/funeral home
Residence
Station or quarters
Other
Activity at Time of Injury

Activity at time of injury

during past 24 hours

Vehicle Type
Complete ONLY if
J4
Primary Apparent Symptom
Cause of Firefighter Injury
Object Inv
Specific Location code
H
1
I1
I3 in Injury
is >60
1
Physical Condition
Just Prior vehicle
to Injury
Suppression
Not transported
G651 In aircraft
G2
G4 Taken To
2
EMS vehicle
64 DD In boat,
ship, or barge
Complete
1
Cause of injury
Primary
apparent symptom
1
Hospital
3
YYYY
Other
FD
vehicle
e MM
0
Other
NFIRS–5
1
Rested
Block J4
In
rail vehicle
Delete
163
Suppression
4
Doctor’s
4
Non-FD
vehicle
Undetermined
U Primary
2
Fatigued
ty
Noneoffice
Fire
Service
Factor
Contributing
to
Injury
Part
of
Body
Injured
61
In
motor
vehicle
EMS
None
Incident 2
Date
Station
Incident Number
5
Morgue/funeral
H2 Exposure
I2 home
Change
Ill or injured
4
Casualty
In
sewer
354
Prevention
Residence
6
Object involved in injur
In
tunnel
453
Training
Remarks
Station or quarters
7
Severity
49
In structure
Contributing factor
Primary
injured
body
part
5
Maintenance
G
3 Male
Other
0
Career
45
In attic
1
1 only,
1
Report
including exposure
00
Other
C Casualty Number
636
Communications
In
water
Identification
Number
FemaleFirst aid
Volunteer
2
2 only
UU
Undetermined
2
ity 735
Administration
Specific
Location
Where
Activity
at Time
of Injury
In
well
Vehicle Type
Where
Injury
Occurred
C
3
Treated by physician
(no
lost time)
G5 J3 Injury Occurred
J4
834
Fire
investigation
J1
S
In
ravine
4
Casualty Number
Moderate
(lost
time)
is
033
Other
In
quarry or mine
1Suffix En route to FD location
1
Suppression vehicle
Last Name
MI
5
Severe
(lost
time)
32
In ditch or trench
65
In
aircraft
2
2
At FD location
EMS vehicle
6
Life threatening (lost time)
In open pit
64
In boat, ship, or barge
Complete
ed 31
3
Other FD vehicle
3
En route to incident scene Activity at time of injury
Block J4
7
Death
28
On steep grade
63
In
rail
vehicle
Midnight is 0000.
Responses
4
Non-FD vehicle
and Time of Injury
4
En route to medical
facility
27
On fire escape/outside
stairs
61
In motor vehicle
E Date
F
5
At scene in structure
26
On vertical surface or ledge
54
In sewer
of Injury
of Injuryfailed and
If protective Time
equipment
of Birth25
On ground
ladderDate
53
In tunnel Object Involved
Primary
Apparent
Symptom
of Firefighter
6 this Cause
At scene
outside Injury
was a factor in
injury,
please
None Remarks
H241 On aerial ladder or in basket
I
1
I3 in Injury
49
In structure
complete the7other side
of this
At medical
facility
Number of prior responses
23
On roof
45
In
attic
form.
during past 24 hours
00
Other
h
Day
Year
Month
Day
Year
8
Returning
from
incident
Hour
Minute
22
Outside at grade
36
In water
NFIRS–5 Revision 01/01/05
UU
Undetermined
of injury
Primary apparent symptom
9 Cause
Returning
from med facility
35
In well
0
Other
None
34
In
ravine
Factor Contributing to Injury
Primary Part of Body Injured
I2U ToUndetermined Not transported 33 NoneIn quarry or mine
G2 H2Physical Condition Just Prior to Injury G4 Taken

Enter the date and time of the injury in Section E. When the injury date is the same as the date of the
incident, enter the same date information that you entered in the arrival block of Section E of the
Basic Module. If the injury date is different, then enter the correct month, day, and year.
The time, both hours and minutes, of the injury is entered using the 24-hour clock, where midnight is 0000.

Section F: Responses

1
2
4

Record the number of incidents that the casualty responded to within the 24-hour period immediObjector
involved
in injury
32
In ditch
trench
ately prior to the time of injury.
1
Hospital
0
Other
Rested
In open pit
Story Where
Injury Occurred 31
Contributing
factor
Primary injured body part
4
Doctor’s
office
J2
28
On steep grade
Undetermined
U
Fatigued

5
Morgue/funeral home
27
On fire escape/outside stairs
Ill or injured
Check this box and enter the story if the
1 Residence
6
26TypeOn vertical surface or ledge
Specific
Location
Where
injury occurred inside or on a structure Vehicle
Where Injury Occurred
Complete ONLY if
J
3
25
On ground ladder Specific Location code
JSeverity
1
Station or quarters J4
7
Injury Occurred
Story of injury
Below grade
is >60
G3 11 En route to FD location
24
On aerial ladder or in
basket
Other
0
1
Suppression vehicle
Report only, including exposure
23
On roof
65
In aircraft
2
2
At
FD
location
EMS
vehicle
2
First aid only
22
Outside at grade
Injury
outside
64
In boat, ship,
2or barge
Activity
atoccurred
Time
of Injury
Complete
3
Other FD vehicle
En
route by
to incident
scene
33
Treated
physician
(no lost time)
Block J4
G5vehicle
63
In rail
4
Non-FD vehicle
En
route to(lost
medical
44
Moderate
time)facility

5-5

In motor vehicle

If protective equipment failed and
was a factor in this injury, please
complete the other side of this
form.

NFIR

Injured Person

First Name
NFIRS
5.0 Self-Study Program

1
2

Identification Number

Male
Female

1
2

Last Name

Suffix

Age or Date of Birth

Date and Time of Injury

Section G: Usual Assignment, Physical Condition Just Prior
OR
To Injury, Severity, Taken To, Activity
at Time of Injury
FDID

State

Injured Person

A
B

FDID

State

First Name

Injured Person

Age or Date of Birth

Date of Birth

In years

Month

Date of Injury

Day

Year

Month

Day

Year

Midnight is 0000.

Time of Injury

Hour

YYYY
Usual
Assignment

Describe theAgeofficial assignment of the casualty in Block G1. This may or may not coincide with the
OR
Number of prior responses
firefighter’s activity
at the
timeMonth
of injury.
during past
24 hours
Midnight is 0000.
In years
Responses
Day
Year
MonthDate
Day
Year
Hour
Minute
Primary
Apparent
Symptom
Cause of Firefighter
Injury
and Time
of Injury
D Age or Date of Birth
E
F
H1
I1
First Name

Age

Usual Assignment

In years

Minu

Physical Condition Just Prior Delete
to Injury NFIRS–5 Taken To
G4
Fire Service
Incident Date
Station
Incident Number
Exposure
Change
1
Hospita
Casualty
0
Other
1
Rested
1
Suppression
4
Doctor’
Undetermined
U
2
Fatigued
2
EMS
5
Morgue
Ill or injured
4
MM
DD
YYYY
NFIRS–5
Casualty
Number
3
Prevention
Male
Career
1
1
Delete
Residen
6
C
Fire
Service
4
Training
Identification Number
Female
Volunteer
2 Incident
2
Station
7
Severity
Incident Date
Station
Number
Exposure
Change
Casualty0
5
Maintenance
G3 1
Other
Report
only,
including
exposure
6
Communications
Casualty Number
2
First aidSuffix
only
7
Administration
Last Name
MI
Activity at T
Male3
Career
Treated
by physician (no Casualty
1
G5
8
Fire investigation 1
C lost time)Number
4
Moderate
(lost
time)
Identification
Number
Female
Volunteer
2
2
0
Other
0000.
5
Responses
SevereMidnight
(lost istime)
E Date and Time6of Injury
FCasualty Number
Life threatening (lost time)
Activity at time of injury
7
Death Time
Suffix
Date of Injury
of Injury
Date MI
of BirthLast Name
MM

Age

Career
Volunteer

Date of Birth

G2
Month

1
2
4

Date of Injury

PhysicalPrimary
Condition
Just Prior to Injury
apparent symptom

Day
Part
of Body
Injured Year
0 Month
Other
HRested
2
Undetermined
U
Fatigued
Ill or injured
PhysicalPrimary
Condition
Just Prior to Injury
injured body part

Day

Time of Injury

Year
Primary

Taken To

Cause of injury

Not oftransported
Number
prior responses

during past 24 hours
None
Factor Contributing
to Injury
1 HourHospital
Minute

I2
4
Doctor’s
office
O
5
Morgue/funeral home
To Contributing factor Not transported
G4 67TakenResidence
Station or quarters
Severity
1
Hospital
0 DeleteOtherNFIRS–5
1
Rested
Other
0
2
1
Report
only,
including
exposure
Specific
Location
Where
Vehicle Type
4
Doctor’s
office
Where Injury
Fire Service
Undetermined
U Occurred
2
Fatigued
J3 Injury 5Occurred
J4
J
1First
2
aid only
Exposure
Morgue/funeral
home
Change
Ill or injured
4
Casualty
Activity at Time of Injury
3
by physician
(no lost time)
1 Treated
En route
to FD location
1
G5 6
Residence
Suppressio
65
In aircraft
4 Severity
(lost time)
2
2 Moderate
At FD location
Station or quarters
7
EMS vehic
In boat, ship,
or barge
Complete
5
(lost to
time)
3
Casualty
Number64
Other
Other FD v
0
Career
3 Severe
En
route
incident
scene
11
Block
J4
Report
only, C
including
exposure 63
In rail vehicle
6
LifeEn
threatening
(lost time)
4
Non-FD ve
Volunteer
4 First
22
route
to medical
facility
Activity atvehicle
time of injury
61
In
motor
aid
only
7
Death
Activity at Time of Injury
5 Treated
At scene
in structure
3
by physician
(no lost time)54 GIn5 sewer
53
In tunnel
6 Moderate
At scene
outside
Casualty Number
4
(lost
time)
Remarks
49
In structure
7Suffix
At medical
facility
5
Severe
(lost time)
Cause of Firefighter
Injury
Object Involved
None
45
In
attic
I1 from
00 I3 Other
6
threatening
(lost
time)
8 LifeReturning
incident
in Injury
Activity at time of injury
36
In water
UU
Undetermined
7
Death
Midnight
is 0000.
9
Returning
from
med
facility
Responses 35
In well
E Date and Time of Injury 0 Other
F
Cause of injury
Primary apparent symptom
34
In ravine
U of Injury
Undetermined
33
In quarry or mine
Date of Injury
Time
None
Factor
Contributing
to
Injury
Primary Apparent
Part of Body
Injured
Symptom
Cause of Firefighter Injury
Object Involved
In ditch or trench
None
None
I12 Number of prior responses 32
I3 in Injury
31
In open pit
Story Where Injury
Occurred
Object
involved
in
injury
during past 24 hours
JHour2 Minute
28
On steep grade
Month
Day
Year

1
Suppression
2
EMS
3
Prevention
Assignment
G41 Usual
G2
Training
MM
DD
YYYY
5
Maintenance
G3
1
Suppression
6
Communications
2
EMS
Incident Date
Station
Incident
Number
7
Administration
3
Prevention
8
Fire investigation
4
Training
0
Other
5
Maintenance
Male G3
1
6
Communications
Identification Number
Female
2
7
Administration
8
Fire investigation
0
Other
Last Name
MI
Primary Apparent Symptom
H1

None

Record the general physical condition of the casualty just prior to the injury in Block G .

State

son

of Birth
Date of Birth

OR
Month

DescribeHthe
severity or seriousness of the casualty in relation to death and time lost from work in
2
1
Block Year
G3.
Day

27
On fire escape/outside stairs
26
On vertical surface or ledge
If protective equipment failed
None
Factor Contributing
Primary
Part of
25to Injury
On groundNone
ladder
nment
Physical Condition
Just Prior
to Body
InjuryInjured
was a factor in this injury, ple
2
2
Story of injuryWhere
To Location
Specific
Below
grade
Vehicle
Type or in basket
Not
transported
2
4 3Taken
Where Injury Occurred
24
On
aerial ladder
Complete complete
ONLY if
the other side of th
4
1
Object involved in injury
Specific
Location
Injury
Occurred
23
On roof
form. code
Hospital
1
is >60
0
Other
1
Rested1
En
route
tobody
FDpart
location
22
Outside
at grade
1
ion
Suppression
vehicle
Contributing factor
Primary
injured
Injury occurred
outside
office
4 2 Doctor’s
Undetermined
U
2
Fatigued
65
In aircraft
2
2
At FD location
EMS vehicle
Morgue/funeral
home
5
Ill or injured
4
64
In
boat,
ship,
or
barge
Complete
3
n
Other FD vehicle
3
En route to incident scene
Location Where Block J4
636 Specific
InResidence
rail vehicle
Type vehicle
Where Injury Occurred
Complete ONLY if
4Vehicle
Non-FD
3
4 1 En route to medical facility
or
quarters
4
Severity
617 Injury
InStation
motor
vehicle
Specific Location code
Occurred
nce
3
is >60
5
At
scene
in
structure
Other
0
54
In sewer
route toexposure
FD location
1
Suppression vehicle
1
Report1only,En
including
cations
53
tunnel
6
At
scene
outside
65
In
aircraft
2
2
At
FD
location
EMS
vehicle
Remarks
2
First aid only
ation
49 Activity
structure
atship,
Timeorofbarge
Injury Complete
64
In boat,
7 by physician
At medical
facility
3
Other FD vehicle
3
3
En
route to
incident
scene
Treated
(no
lost time)
5 63
Block J4
tigation
45
atticvehicle 00
In
rail
Other
4
8 (lost
Returning
incident
4
Non-FD vehicle
4
Moderate
time) tofrom
4
En
route
medical
facility
36
water vehicleUU
61
In motor
Undetermined
9(lostAt
Returning
med facility
5
Severe5
time)
35
well
scene infrom
structure
54
In sewer
0
Other
6
Life threatening
(lost outside
time)
34
ravine
53
tunnel
6
At
scene
Activity atIn
time
of injury
Remarks
Undetermined
33
quarry or mine
7
Death 7U
49
In structure
At medical facility
32
ditch or trench
45
In attic
00
Other
8
Returning from incident
31
open pit
In water
Story Where Injury Occurred 36
UU
Undetermined
9 2 Returning
med facility
28
Onwell
steep gradeObject Involved
In
parent Symptom
Cause from
of Firefighter
Injury 35
None
0
1Other
3 in Injurystairs
27
Onravine
fire escape/outside
34
In
this box and enter the story if the
1U Check
26
On
vertical
surface
or
ledge
Undetermined
33
In
quarry
or
mine
injury occurred inside or on a structure
If protective equipment failed and
25
Onditch
ground
ladder
32
In
or trench
was a factor in this injury, please
Cause
injury
ymptom
Story ofofinjury
Below grade
24
Onopen
aerialpitladder or in basket
31
In
complete the other side of this
Story Where Injury Occurred
23
On
roof
form.
None
2
28
steep grade
Factor Contributing to Injury
t of Body Injured
None at grade
2
22
Outside
27
On fire escape/outside stairs
Injury occurred outside
NFIRS–5 Revision 01/01/05
2
Check this box and enter the story if the
1
26
On vertical
surface
ledge
Object
involvedor
in injury
injury occurred inside or on a structure
If protective equipment failed and
25
On ground ladder
was a factor in this injury, please
Contributing
factor Below grade
y part
Story of injury
24
On aerial ladder or in basket
complete the other side of this
23
On roof
form.
22
Outside
Injury occurred
outside
Specific Location
Where
NFIRS–5 Revision 01/01/05
Vehicle
Type at grade
2
Occurred
Primary apparent
injured body
part
Primary
symptom

H
J

Contributing
factor
Cause of injury
Check this box and enter the story if the
injury occurred inside or on a structure

G casualty went after the injury.
Use Block G to record where the

5-6

Injury Occurred

Complete ONLY if
Specific Location code

nment

1
2
4

ce
ations
tion
igation

Physical Condition Just Prior to Injury

arent Symptom

mptom

of Body Injured

Rested
Fatigued
Ill or injured

0
U

Other
Undetermined

Severity
1
2
3
4
5
6
7

Report only, including exposure
First aid only
Treated by physician (no lost time)
Moderate (lost time)
Severe (lost time)
Life threatening (lost time)
Death

G4
A

Taken To

NotMM
transported
DD

YYYY

1
Hospital
Incident Date
4FDID Doctor’s office
State
5
Morgue/funeral home
Residence
6 NFIRS
5.0 Self-Study Program
Station
7
Injured
Personor quarters
Other
0
Identification Number

GName
5
AFirst

Activity at Time of Injury MM

FDID

Age

Male
Female

1
2

Exposure

Career
Volunteer

1
2

Suffix
Exposure

Incident Number

Date of BirthIdentification Number

Career
Time of Injury
Volunteer

Use Block G5 to
describe
whatInjury
type of activityORwas
taking
place atNone
the time the injury occurred.
Cause
of Firefighter
Object
Involved
I1
I3 in Injury
In years
Month
Day
Year
Month
Day
Year
Hour
Minute
First Name
Last Name
MI
You will need to enter a code as
part of the description.
Use
the NFIRS Complete Reference Guide (CRG)Suffix
of injury
to identify theCause
activity
of the firefighter
at the time of the injury.
Usual Assignment
Just Prior to Injury
Midnight is 0000.
None
To
Factor Contributing to
Injury
Date and Time of Injury
G
1 Age or Date
G2 Physical Condition E
G4 Taken
None of Birth
D
I2
Rested
Fatigued
Ill or injured

0 Date ofOther
Injury
Undetermined
U

Cha

Midnight is 0000.

Date and Time of Injury
Male
1
1
Date of Injury2
Female
2

in injury 1
Age SuppressionObject involvedDate
of Birth

Cha

Casu
Dele
Station

Activity at time of injury
Age
or Date of Birth
Injured Person

D
B

Incident Number

YYYY

Last Name
MI
Incident Date

State

Dele
Station

1
4
5
6
7
0

FCas

Num
durin
Casu

Hospital
Time of Injury
Doctor’s office
Morgue/funeral Num
ho
durin
HourResidence
Minute
Station or quarters
Other

1
2
2
EMS
OR
4
3 In years
Prevention
Month
Day
Year
Month
Day
Year
4
Training
Specific Location Where
Severity
Vehicle Type
Occurred
Complete ONLY if
J3 Injury Occurred
5
Maintenance
G
3
J4
Specific Location code
1
Report only, including exposure
is >60 Physical
6
Communications
Assignmentvehicle
Condition Just Prior to Injury
D location
1 Usual
Suppression
To
2
First aid only
G
1
G
2
G4 Taken
7
Administration
Activity at Time of InjuN
65
In
aircraft
2
n
EMS vehicle
3
Treated
by physician (no lost time)
G
5
8
Fire
investigation
1
Hospital
64
In boat, ship, or barge
Complete
Rested
3 Suppression
Other FD vehicle
cident scene
41
Moderate (lost 0time) Other
1
Block J4
0
Other
63
In rail vehicle
4
Doctor’s office
Undetermined
U
Fatigued
Non-FD vehicle
52
edical facility
Severe (lost time)
1
2 4 EMS
61
In motor vehicle
5
Morgue/funeral ho
Ill
orthreatening
injured
4
6
Life
(lost
time)
ructure
3
Prevention
54
In sewer
Activity
of injury
Residence
6 at time
7
Death
53
In tunnel
4
Training
ide
Station or quarters
7
Remarks
Severity
49
In structure
5
Maintenance
G3 1
cility
Other
0
Report only, including exposure
45
In attic
6
Communications
00
Other
m incident
36
In water
2
First
aid
only
Primary
Apparent
Symptom
Cause
of
Firefighter
Injury
Object
UU
Undetermined
Activity at Time
Injur
m med facility
H781 Administration
I3 inofInjur
35
In well
3
Treated byI1physician (no lost
time)
MM
DD
YYYY
G
5
NFIRS–5
Fire investigation
Delete
A 34 In ravine
4
Moderate
(lost
time)
0
Other
Fire Service
d
33FDID In quarry or State
mine
Incident Date
Incident Number
Exposure (lost time)
5
Severe
Cause
of injury
PrimaryStation
apparent symptom
Change
Casualty
32
In ditch or trench
6
Life threatening (lost time)
Activity at time of injury
None
In open pit
Factor Contributing to Injury
Primary Part of Body Injured 7
njury Occurred 31
None
Death
H2
I2
28
On steep grade
Injured
Casualty Number
Male
Career
1
1
27
OnPerson
fire escape/outside stairs
Object involved in
C
er the story if the B
26
On vertical surface or ledgeIdentification Number
Volunteer
2 part Female
2
r on a structure
Contributing factor
Primary
injured
body
If protective
equipment
failed
and
Primary Apparent Symptom
Cause of Firefighter Injury
Object
25
On ground ladder
was
H1a factor in this injury, please
I1
I3 in Injur
Below grade
24
On aerial ladder or in basket
complete the other side of this
Casualty Number
23
On roof
form.
Specific
Location Where
First Name
Last Name
Vehicle Type
MI
Suffix
Where Injury Occurred
J3 Injury
22
Outside at grade
J4
J1 Primary apparent symptom
NFIRS–5 Revision
01/01/05
Occurred Cause of injury
1
En
route Part
to FDoflocation
1
Suppression vehicle
None
Primary
Body Injured
FactorResponses
Contributing to Injury
Midnight is 0000.
None
In aircraft I2
H
Date and Time of Injury65
2
2 2 At FD
EMS vehicle
D Age or Date of Birth
E location
F
64
In boat, ship, or barge
Complete
Object involved in
3
Other
FD vehicle
3
En route to incident scene
Block J4
63 TimeInofrail
vehicle
Date of Injury
Injury
Age
Date of Birth
4
Non-FD vehicle
4
En
route
tobody
medical
facility
Primary
injured
part
61
In motor vehicle Contributing factor
5
At scene in structure
54
In sewer
OR
Number of prior responses
during past 24 hours
In years
53 HourIn tunnel
Month
Day
Year 6
Month outside
Day
Year
At scene
Minute
Remarks
Specific
Location
Where
Vehicle Type
Where Injury Occurred
In structure
2
J493 Injury
7
J4
J1 At medical facility
Occurred
45
In attic
00
Other
8
Returning
incident
1
En
routePrior
tofrom
FD
1
Suppression vehicle
36
In water
Just
tolocation
Injury
UU
Undetermined
In
aircraft
9
Returning
from med facility
Not transported
G1 Usual Assignment
G2 Physical Condition
G4 65
2
2
At
FD location
EMS vehicle
35Taken
InTo
well
64
In
boat,
Complete
0
Other
34
In
ravineship, or barge
3
Other FD vehicle
En
to incident scene
1
Hospital
Block J4
0routeOther
1
Rested 3U
63
In
rail
vehicle
Undetermined
33
In
quarry oroffice
mine
1
Suppression
4
Non-FD vehicle
4
4
Doctor’s
En
to medical facility
UrouteUndetermined
2
Fatigued
61
In
motor
vehicle
32
In ditch or trench
2
EMS
5
Morgue/funeral
home
5
At scene in structure
54
In
sewer
Ill or injured
4
31
In open pit
3
Prevention
Where
Injury Occurred 53
Residence
6
In
6J2 Story
At scene
outside
28
Ontunnel
steep grade
Remarks
4
Training
49
In
structure
Station
or quarters stairs
7
Severity
7
At medical facility
27
On
fire escape/outside
5
Maintenance
Check
this
box
and
enter
the
story
if
the
G3 1
45
In
attic
Other
0
1
26
On vertical surface
00 or ledge
Other
Returning
from
occurred inside
or onincident
a structure
Report 8only,injury
including
exposure
6
Communications
If protective equipment failed and
36
In
25
Onwater
ground ladder
UU
Undetermined
from med
facility
2
First aid9 onlyReturning
was a factor in this injury, please
Story of injury
35
In
well
Below grade
7
Administration
at Time
of or
Injury
24 Activity
On aerial
ladder
in basket
complete the other side of this
3
Other
Treated0by physician
(no lost time)
In
G5 34
8
Fire investigation
23
Onravine
roof
form.
4
Moderate
time)
U (lost
Undetermined
33
In
quarryatorgrade
mine
0
Other
22
Outside
Injury
occurred
outside
2
32
In
ditch
or
trench
5
Severe (lost time)
31
In open pit
6
Life threatening
time)
Story(lost
Where
Injury Occurred Activity
at time of injury
28
On steep grade
7
Death J2
Contributing factor

part

Section H: Primary Apparent Symptom and
Primary Area of Body Injured

Record the primary symptom and areas of injury in Section H. Use Block H to enter the code that
describes the casualty’s most serious injury.

The Emergency Medical Technician (EMT) or the person responsible for the prehospital emergency
care phase of treatment may provide you with a determination of what appears to be the casualty’s
most serious injury.

Block H is used to record the body part or area that sustained the most serious injury. It should be
the part of the body affected by the primary apparent symptom.

Section I: Cause of Firefighter Injury,
Factor Contributing to Injury, and Object Involved in Injury

In Section I, record the data that describes the factors that caused the injury. Use the CRG to complete
this section.
1

Primary Apparent Symptom

I
2

Primary apparent symptom

27
26
Cause
of Firefighter
Injury 25
Story of injury
Below grade
24
1
23
22
Injury occurred outside
Check this box and enter the story if the
injury occurred inside or on a structure

On fire escape/outside stairs
On vertical surface or ledge
On ground ladder
Object Involved
On aerial 3ladder or in basket
in Injury
On roof
Outside at grade

If protective equipment failed and

Nonewas a factor in this injury, please

Cause of injury

None

Factor Contributing to Injury
None
I2
Use Block I1 to describe the situation or circumstance that directly resulted
in the casualty.
Object involved in injury

Primary Part of Body Injured

Contributing factor

Primary injured body part

Where Injury Occurred

1
2
3

En route to FD location
At FD location
En route to incident scene

Specific Location Where
Injury Occurred

65
64

In aircraft
In boat, ship, or barge

5-7J4
Complete
Block J4

Vehicle Type
1
2
3

Suppression vehicle
EMS vehicle
Other FD vehicle

Complete ONLY if
Specific Location code
is >60

complete the other side of this
form.

Month

Day

Year

Month

Day

6Year
7

Physical Condition Just Prior to Injury
Primary Apparent Symptom
H1Rested
0
Other
1
Undetermined
U
2
Fatigued
Primary
apparent symptom
Ill or
injured
4

Life threatening
(lost time)during past 24 hours
Hour
Minute
Death

Activity at time of injury

Injured Person
A
Taken To B
Not transported
FDID
State
Cause of
Firefighter
Injury
IHospital
1
1
NFIRS 5.0 Self-Study Program
4
Doctor’s office
First Name
5
Morgue/funeral
home
Cause of injury
Injured
Person
B
Residence
6
None
Factor
Contributing
to Injury
or quarters
7
IStation
2
Age
or
Date
of
Birth
Other
0
D

YYYY

Number
Incident Identification
Date
Object

Station
Involved
in Injury

Female
Incident
Number

Male

1
2

Career
Volunteer
Exposure

1
2

Male
Female

1
2

Career
Volunteer

None

Last Name

1
2

Suffix

Identification Number
Primary Part of Body Injured
None
Severity
Midnight is 0000.
H2
E Date and Time of Injury
Object involved in injury
1
Report only, including exposure
First Name
Last Name
MI
Suffixof Injury
Date of Injury
Time
2
First
aidinjured
onlybody part
Age
Date of Birth
Contributing
factor
Primary
Activity at
Time of
Injury
3
Treated by physician (no lost time)
G5
OR
4
Moderate (lost time)
Midnight is 0000.
In
yearsor Date of Birth
MonthType Day
Year
Specific Location Where
Age
Date Day
and TimeYear
of Injury
Hour
Minute
Vehicle
Where(lost
Injury
Occurred
5
Complete
ONLY if
Severe
time)
D
EMonth
J
3
J
4
J
1
Specific Location code
Injury
Occurred
6
Life threatening (lost time)
is
>60
Activity at time of injury
Date of Injury
Time of Injury
Age
of Birth
En route to FD2 location
1 Date
Suppression
vehicle
7 1 Death
Usual Assignment 2
Physical Condition Just Prior to Injury
65
In aircraft
2
At FD location
EMS
vehicle
Taken
To
G1 Complete
G2
G4
OR
64
In boat, ship, or barge
3 Month
Other FD
3
En route to incident scene
In years
Day vehicle
Year
Month
Day
Year
Block J4
Hour Hospital
Minute
1
63
In rail vehicle
0
Other
1 vehicle
Rested
mptom
Cause facility
of Firefighter
Object
Involved 4 NoneNon-FD
4
En route to medical
1
Suppression
61 Injury
In motor vehicle
4
Doctor’s o
I
1
I
3 in Injury
Undetermined
U
2
Fatigued
5
At scene in structure
2
EMS
54
In sewer
5
Morgue/fu
Ill or Condition
injured Just Prior to Injury
4 Physical
Usual
Assignment
3
Prevention
53
In tunnel
6
At scene outside
6TakenResidenc
To
Remarks G2
G
1
G
4
Cause of injury
49
In structure
4
Training
7
At medical facility
Station or
7
Severity
1
Hospital
45
In attic
Maintenance
0
Other
Rested
G3 11
00 5 Other
None
Other
8
0
Returning from
incident
Factor
Contributing to Injury
njured
Suppression
Report only, including
exposure
4
Doctor’s o
I2 from med facility 36 In water NoneUU 126 Undetermined
Communications
Undetermined
U
2
Fatigued
9
Returning
EMS
35
In well
2
First
aid
only
5
Morgue/fu
7Object involved
Administration
Ill or injured
4
in injury
Activity at Tim
0
Other
3
Prevention
34
In ravine
3
Treated by physician (no lost time)
Residence
G5 6
8
Fire investigation
U
UndeterminedContributing factor
33
In quarry or mine 4
Training
4
Moderate (lost time)
Station or
7
Severity
0
Other
32
In ditch or trench 5
Maintenance
G3 15
Severe (lost time)
Other
0
31
In
open
pit
Report
only,
including
exposure
3
6
Communications
StoryLocation
Where Injury
Occurred
6
Life threatening (lost time)
Specific
Where
Vehicle
Type
Activity at time of injury
J
2
28
On
steep
grade
Complete
ONLY
if
2
First
aid
only
J3 Injury Occurred
7
Administration
J4 On fire escape/outside
7
Death
Activity at Tim
Specific Location code
27
stairs
3
Treated by physician (no lost time)
G5
is >60
8
Fire investigation
Check this box and enter the story if the
1
1
26
On
vertical
surface
or
ledge
Suppression
vehicle
injury occurred inside or on a structure
4
Moderate (lost time)
0
Other
If protective equipment failed and
65
In aircraft
25
On2 ground
ladder
EMS
vehicle
5 please
Severe (lost time)
was a factor in this injury,
of injury
64
In boat,Story
ship,
or bargeBelow grade
Primary
Apparent
Symptom
Cause of Firefighter Injury
Complete
24
On
aerial
ladder
or
in
basket
3
Other FDH
vehicle
complete the other side
ene
6 of thisLife threatening
1
I1 (lost time)
I3
Block J4
63
In rail vehicle
Activity at time of injury
23
On4 roof Non-FD vehicle
form.
ility
7
Death
61
InInjury
motor
vehicle
22
Outside
at
grade
occurred outside
NFIRS–5 Revision 01/01/05
2

t
cility

urred

Enter the code and description for the most significant factor contributing to the casualty’s injury in
Block I .

Then enter the code and description of the object that contributed to the injury in Block I .

54
53
49
45
36
35
34
33
32
31
28
27
26
25
24
23
22

Section J: Where Injury Occurred, Story Where Injury
Occurred, Specific Location, and Vehicle Type

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

Cause of injury

Primary apparent symptom

Remarks

H
H12

None

Primary
Symptom
Primary Apparent
Part of Body
Injured

II12

Cause
Firefighter Injury
Factor of
Contributing
to Injury

Section J is completed to describe the location where the injury occurred.
Primary Part of Body Injured
Where Injury Occurred

En
route
FDpartlocation
1
Primary
injuredto
body
At FD location
2
If protective equipment failed
3 andEn route to incident scene
was a factor in this injury, pleaseWhere Injury Occurred
4this
1 En route to medical facility
complete the other side ofJ
form.
At scene
in FD
structure
15
En
route to
location
NFIRS–5
Revision 01/01/05
At FD
scene
outside
26
At
location
At medical
37
En
route to facility
incident scene
Returning
incident
48
En
route tofrom
medical
facility
Returning
med facility
59
At
scene infrom
structure
Other
60
At
scene outside
Undetermined
7U
At
medical facility
8
9J2
0
1
U

Returning from incident
Story
Where
Injury
Occurred
Returning
from
med
facility
Other
Check this box and enter the story if the
Undetermined
injury
occurred inside or on a structure

Story Where Injury Occurred

J3
65
64
63
3
61
54
65
53
64
49
63
45
61
36
54
35
53
34
49
33
45
32
36
31
35
28
34
27
33
26
32
25
31
24
28
23
27
22
26
25
24
23
22

Mark the boxes in Block J1 to indicate where the injury occurred.
Story of injury

2
1

Injury occurred outside
Check this box and enter the story if the
injury occurred inside or on a structure
Story of injury

Below grade

Injury occurred outside

Below grade

Obj

None
Factor Contributing to Injury
None
I2 Where
Specific Location
Vehicle Type
J
4
Obje
Injury Occurred
Contributing factor
1
Suppression
In aircraft
2
EMS vehicle
In boat, ship, or barge
Complete
3
Other FD veh
Specific
Location Where Block J4
Vehicle Type
In rail vehicle
Non-FD vehi
J4 4
Injury Occurred

In motor vehicle
In sewer
In
In aircraft
tunnel
In
ship, or barge
In boat,
structure
Complete
Block J4
In
In rail
atticvehicle 00
Other
In
In motor
water vehicleUU
Undetermined
In
In sewer
well
In
In tunnel
ravine
In
In structure
quarry or mine
In
In attic
ditch or trench
00
Other
In
In water
open pit
UU
Undetermined
In
Onwell
steep grade
In
Onravine
fire escape/outside stairs
In
or surface
mine or ledge
Onquarry
vertical
In
or trench
Onditch
ground
ladder
In
pitladder or in basket
Onopen
aerial
On
On steep
roof grade
On
fire escape/outside
stairs
Outside
at grade
On vertical surface or ledge
On ground ladder
On aerial ladder or in basket
On roof
Outside at grade

1
2
Remarks
3
4

5-8

Suppression
EMS vehicle
Other FD veh
Non-FD vehic

Remarks

If protective equipment failed an
was a factor in this injury, pleas
complete the other side of this
form.

If protective equipment failed an
was a factor in this injury, please
complete the other side of this
form.

For Block J2, check Box 1 if the person was inside or on the structure, and enter the story where the
injury occurred on the line provided.
Check Box 2 if the injury occurred outside.

Cause
of injury
Contributing
factor

Primary
symptom
Primaryapparent
injured body
part

H2
J1

None

rson
Identification Number

Last Name

1
2
Primary apparent symptom

Male
Female

Career
Volunteer

1
2

gnment

sion

nce
ications
ration
stigation

Where Date
Injury
Occurred
of Injury

En route to FD location
Month
Day
Year
At FD location
3
En route to incident scene
4
En route to medical facility
Just Prior to Injury
At scene in structure
G2 Physical 5Condition
6
At scene outside
0
Other
1
Rested
7
At medical
facility
Undetermined
U
2
Fatigued
Returning from incident
Ill or 8injured
4
9
Returning from med facility
Other
Severity 0
G3 1
U only,
Undetermined
Report
including exposure

parent Symptom

2
3
4
5
6
7

First aid only
Where(no
Injury
Treated
physician
lostOccurred
time)
J2 byStory
Moderate (lost time)
Checktime)
this box and enter the story if the
Severe
1 (lost
injury occurred inside or on a structure
Life threatening (lost time)
Story of injury
Below grade
Death
2

Injury occurred outside

rt of Body Injured

Object involved in injury

Responses

Specific
Location Where
Time of Injury
Injury Occurred

Vehicle Type

Number of prior responses

Suppression vehicle

during past 24 hours
65
In
aircraft
Hour
Minute
2
EMS vehicle
64
In boat, ship, or barge
Complete
3
Other FD vehicle
Block
J4
63
In rail vehicle
4
Non-FD vehicle
61
In motor vehicle
To
Not transported
4 Taken
54
In sewer
53 1 In tunnel
Hospital
Remarks
49 4 In structure
Doctor’s office
45
In attic
00 home
Other
5
Morgue/funeral
36
In water
Undetermined
Residence UU
35 6 In well
Station or quarters
34 7 In ravine
Otheror mine
33 0 In quarry
32
In ditch or trench
31
In open at
pit Time of Injury
Activity
5
28
On steep grade
27
On fire escape/outside stairs
26
On vertical surface or ledge
If protective equipment failed and
25ActivityOn
ground
at time
of injury ladder
was a factor in this injury, please
24
On aerial ladder or in basket
complete the other side of this
23
On roof
form.
22
Outside at grade

Complete ONLY if
Specific Location code
is >60

Cause of Firefighter Injury

Object Involved
in Injury

NFIRS–5 Revision 01/01/05

I1
I3
Block J3 is used to identify the casualty’s specific location at the time of the injury.
None

Cause of injury

symptom

Note None
the codes Factor
by theContributing
specific location
If you selected a vehicle code greater than 60,
to Injury descriptions.
None
I2
also select the vehicle type in J4.
Object involved in injury
Contributing factor

ody part

y Occurred

FD location
on
incident scene
medical facility
structure
tside
facility
rom incident
rom med facility

ed
Injury Occurred

enter the story if the
e or on a structure

Midnight is 0000.

Date and Time of Injury

Year
2

Day

None

Contributing factor

Month

Factor Contributing to Injury

Casualty Number
I2
NFIRS 5.0 Self-Study Program
Suffix

e of Birth

Casualty Number

Cause of injury

None

Primary Part of Body Injured

Primary injured body part

Date of Birth

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
4
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

Vehicle Type
1
2
3
4

Complete ONLY if
Specific Location code
is >60

Suppression vehicle
EMS vehicle
Other FD vehicle
Non-FD vehicle

Block J is used to identify the Remarks
vehicle type that was involved.

Section K: Protective Equipment

Section K allows you to record Ifdata
involving
protective
equipment. If protective equipment failed
protective
equipment failed
and
was a factor in this injury, please
complete
the other
side ofbox
this in Block K1. Complete the rest of Section K if you
and contributed to the injury, mark
the
“Yes”
form.
have marked the “Yes” box.

NFIRS–5 Revision 01/01/05

Did protective equipment fail and contribute to the injury?

Yes

Please complete the remainder of this form ONLY if you answer YES.

Equipment
Sequence
Number

NFIRS–5

Fire Service
Casualty

Protective Equipment Item
Protective Equipment Problem
NOTE:
K2 Equipment Sequence Number - When more than one piece of protective equipment
K3 was a factor in the casualty’s injury,
Check
one box toconsecutively
indicate the mainstarting
problem that occurred.
a module should be completed for each piece of equipment. Each item is given a number that is assigned
Head or Face Protection
Coat, Shirt, or Trousers
with one (001) and continuing based on how many protective equipment items were 11
involved.Burned
11
12
13
14
15
16
17
10

Helmet
Full face protector
Partial face protector
Goggles/eye protection
Hood
Ear protector
Neck protector
Other

21
22
23
24
25
26
27
28
20

Protective coat
Protective trousers
Uniform shirt
Uniform T-shirt
Uniform trousers
Uniform coat or jacket
Coveralls
Apron or gown
Other

5-9

Boots or Shoes

Knee length boots with steel baseplate and steel toes

Melted

Fractured, cracked or broken

Punctured

Scratched

Knocked off

Cut or ripped

NFIRS 5.0 Self-Study Program

Did protective equipment fail and contribute to the injury?

Yes

Please complete the remainder of this form ONLY if you answer YES.

Protective Equipment Item

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.

Burned

Melted

Fractured, cracked or broken

Punctured

Scratched

Knocked off

Cut or ripped

Trapped steam or hazardous gas

Insufficient insulation

Object fell in or onto equipment item

Failed under impact

Face piece or hose detached

Exhalation valve inoperative or damaged

Harness detached or separated

Regulator failed to operate

Regulator damaged by contact

Problem with admissions valve

Alarm failed to operate

Alarm damaged by contact

Supply cylinder or valve failed to operate

Supply cylinder/valve damaged by contact

Special Equipment

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

Did not fit properly

Not properly serviced or stored prior to use

Not used for designed purpose

Not used as recommended by manufacturer

Other equipment problem

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
Was the failure of more
Personal alert safety system (PASS)
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

Undetermined
Equipment Manufacturer, Model and Serial
Number
Manufacturer

Model

Serial Number

Block K2 is used to record the protective equipment item that failed and was a factor in the casualty’s
injury.
The choices are grouped into the following categories:
• Respiratory Protection
• Hand Protection
• Special Equipment

• Head or Face Protection
• Coat, Shirt, or Trousers
• Boots or Shoes

5-10

NFIRS–5

Revision 05/01/03

nt fail and contribute to the injury?

Yes

r of this form ONLY if you answer YES.

tem

or
tion

K3
Coat, Shirt, or Trousers

Protective coat
Protective trousers
Uniform shirt
Uniform T-shirt
Uniform trousers
Uniform coat or jacket
Coveralls
Apron or gown
Other

21
22
23
24
25
26
27
28
20

with steel baseplate and steel toes
with steel toes only
h steel baseplate and steel toes
h steel toes only
baseplate and steel toes
teel baseplate and steel toes
teel toes only

NFIRS–5

Equipment
Sequence

NFIRS
5.0 Self-Study Program Fire Service
Number
Casualty

Protective Equipment Problem
Check one box to indicate the main problem that occurred.

Burned

Melted

Fractured, cracked or broken

Punctured

Scratched

Knocked off

Cut or ripped

Trapped steam or hazardous gas

Insufficient insulation

Object fell in or onto equipment item

Failed under impact

Face piece or hose detached

Exhalation valve inoperative or damaged

en circuit
ssure) open circuit
t

Harness detached or separated

Regulator failed to operate

r
sk

Regulator damaged by contact

Problem with admissions valve

Alarm failed to operate

Alarm damaged by contact

Supply cylinder or valve failed to operate

Supply cylinder/valve damaged by contact

Supply cylinder—insufficient air/oxygen

Did not fit properly

Not properly serviced or stored prior to use

Not used for designed purpose

Not used as recommended by manufacturer

Other equipment problem

Undetermined

with wristlets
without wristlets

ntry
on-entry
ed, reusable chemical suit
ed, disposable chemical suit
ted, reusable chemical suit
ted, disposable chemical suit
uit

erwater breathing apparatus (SCUBA)

belt
Was the failure of more
y system (PASS)
3 toitem
Use
record
the most
thanKone
of protective
ce
equipment a factor in the

other
ent, other

uted
to the injury.
injury? If so, complete an
additional page of this
form for each piece of
failed equipment.

Equipment Manufacturer, Model and Serial
Number

significant Manufacturer
problem with the piece of equipment that failed and contribModel

Serial Number

5-11

NFIRS–5

Revision 05/01/03

uit for non-entry
apsulated, reusable chemical suit
apsulated, disposable chemical suit
capsulated, reusable chemical suit
capsulated, disposable chemical suit
ction suit
mp suit

uit
ed underwater breathing apparatus (SCUBA)
er
ladder belt
Was the failure of more
ert safety system (PASS)
than one item of protective
ess device
equipment a factor in the
hting
injury? If so, complete an
or tent
additional page of this
ety belt
form for each piece of
failed equipment.
ipment, other
quipment, other

Not properly serviced or stored prior to use

Not used for designed purpose

Not used as recommended by manufacturer

Other equipment problem

Undetermined

NFIRS 5.0 Self-Study Program

Equipment Manufacturer, Model and Serial
Number
Manufacturer

Model

Serial Number
NFIRS–5

Revision 05/01/03

Block K4 provides space to record information about the equipment manufacturer, model number
or type, and the serial number.
Enter the name of the company that made/manufactured the piece of equipment involved on the
first line. Enter the manufacturer’s model name in the next space. If a model name is not available,
you should give a general physical description of the equipment. Enter the manufacturer’s serial
number, usually stamped on the equipment’s identification plate on the last line.

SUMMARY
The Fire Service Casualty Module is used to report fire service personnel injuries, deaths, or exposures while on duty. This casualty information is used by Health and Safety Officers to reduce the
risks associated with all types of work-related casualties. The Fire Service Casualty Module is also
used to collect information about protective equipment that failed and contributed to the injury.
Researchers, educators, equipment makers, design engineers, and governmental regulatory agencies may use the specific information provided to make various determinations, such as which
specific pieces of equipment are involved in casualties. Complete information must be collected
for each individual casualty in order to provide the data needed to make determinations related
to improving job safety.

5-12

NFIRS 5.0 Self-Study Program

EXAMPLE: Highrise Fire
Directions: Read the call information in the example below.Then look at the completed Fire Service Casualty Module form. Look
at each section and follow along with the proper use of the information as applicable to the Fire Service Casualty Module.
On May 21, 1999, FDID #TR300 received a Highrise Box 13-28 at 2235 hours and responded to
2045 Beach Blvd., North Brook, Wisconsin 12345. Fire was reported to be located on the 12th
floor. The crew assigned to Engine 131 was sleeping prior to the call. It was their first call during
a 24-hour shift that began at 0700 hours. E-131 responded with a crew of four personnel from
Station #1. They assigned incident #7865481 to the response.
Ambulance 139 was returning to the station from a previous call and was sent on the box assignment. The ambulance arrived first. Their initial onscene report was of fire showing from the 12th
floor with people trapped. They requested a second alarm. Chief 13 advised E-131 to do search
and rescue and assigned the second engine company to attack the fire and provide a safe exit for
evacuation. The personnel on E-131 consisted of career personnel Captain Tom Jones, Tech. Marc
Helton, F/F Bob Wilson, and F/F Kenny Segal. F/F Wilson was 57 years old and the most experienced in suppression. He led the crew to the stairwell and planned to walk up to the 12th floor.
The building was about 20 years old and did not have an elevator emergency control system. At
2245, as the crew approached the 10th floor F/F Wilson began complaining of chest pains and
shortness of breath, Captain Jones advised the officer in charge that his crew was taking a couple
minutes’ break to rest. At this point F/F Wilson collapsed and stopped breathing. Captain Jones
started CPR on F/F Wilson and advised officer in charge to call for a medic unit for F/F Wilson.
CPR was continued until the arrival of the advanced life support unit. F/F Wilson was removed
from the building and then transported to Mercy General Hospital where he was pronounced
dead at 2350 hours.

5-13

NFIRS 5.0 Self-Study Program

TR300

FDID

YYYY

1999

State

1
2

Usual Assignment
Suppression
EMS
Prevention
Training
Maintenance
Communications
Administration
Fire investigation
Other

Day

Year

1
2
4

Rested
Fatigued
Ill or injured

Cardiac Symptoms

Heart

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

Story Where Injury Occurred

this box and enter the story if the
X Check
injury occurred inside or on a structure
0 1 0 Story of injury
Below grade

Injury occurred outside

Year

Hour

Minute

Number of prior responses
during past 24 hours

Taken To
1
4
5
6
7
0

Other
Undetermined

Not transported

Hospital
Doctor’s office
Morgue/funeral home
Residence
Station or quarters
Other

Activity at Time of Injury

Searching
for victim

Activity at time of injury

Cause of Firefighter Injury

Overexertion

7
None

Object Involved
in Injury

X None

Factor Contributing to Injury

X None
Object involved in injury

Contributing factor

Primary injured body part

0
U

0 0

2 2 4 5

Cause of injury

Primary Part of Body Injured

Day

1 9 9 9

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

Severity
1
2
3
4
5
6
7

Primary Apparent Symptom

Month

Responses

Time of Injury

Physical Condition Just Prior to Injury

Midnight is 0000.

Date and Time of Injury

05
Month

Casualty Number

0 0 1

Date of Injury

In years

Volunteer

Suffix

Date of Birth

057

X Career

1
2

Last Name

Age

1
2
3
4
5
6
7
8
0

Female

Change

Fire Service
Casualty

Casualty Number

Age or Date of Birth

X Male

NFIRS–5

Delete

Exposure

Wilson

First Name

000

Incident Number

Identification Number

Bob

7 8 6 5 4 8 1

Station

Injured Person

001

Incident Date

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

5-14

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

NFIRS 5.0 Self-Study Program

Did protective equipment fail and contribute to the injury?

Yes

Please complete the remainder of this form ONLY if you answer YES.

Protective Equipment Item

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.

Burned

Melted

Fractured, cracked or broken

Punctured

Scratched

Knocked off

Cut or ripped

Trapped steam or hazardous gas

Insufficient insulation

Object fell in or onto equipment item

Failed under impact

Face piece or hose detached

Exhalation valve inoperative or damaged

Harness detached or separated

Regulator failed to operate

Regulator damaged by contact

Problem with admissions valve

Alarm failed to operate

Alarm damaged by contact

Supply cylinder or valve failed to operate

Supply cylinder/valve damaged by contact

Special Equipment

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

Did not fit properly

Not properly serviced or stored prior to use

Not used for designed purpose

Not used as recommended by manufacturer

Other equipment problem

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

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

5-15

Equipment Manufacturer, Model and Serial
Number
Manufacturer

Model

Serial Number
NFIRS–5

Revision 05/01/03

NFIRS 5.0 Self-Study Program

EXERCISE SCENARIO 5-1:
Fire Captain Injury on Scene of Fire
Directions: Read the call information in the exercise below. Use the information provided to complete the Fire Service Casualty
Module form. Compare your work to the answers provided on the completed Fire Service Casualty Module form. If your answers
are different from the ones provided, read over the Fire Service Casualty Module again.
At 0655 on November 21, 1997, the A-1 Alarm Company notified the Regional 9-1-1 dispatch
center of smoke detector activation at the Busy Bee Market located at the corner of First and Main
Streets in the town of North Brook, WI 12345. Engine 45 and Truck 22 from Station 13 of the
North Brook Fire Department (FDID #TR100) were dispatched to the incident at 0658.
Truck 22 arrived at the market at 0705 and reported smoke showing from the one-story building
and water running from under the front door. The crew of the truck company forced entry and
found that a sprinkler head had been activated and was in the process of extinguishing a small
fire behind the clerk’s counter in the market.
Engine 45, which arrived on location at 0707, extinguished the remaining fire and the truck
company ventilated smoke from the market and shut down the sprinkler system. The fire was
declared under control at 0727.
While the crews were cleaning up and putting the sprinkler system back in service, the owner of
the market, Angela Anderson, arrived. She told the Engine Company Captain that she had worked
at the market until midnight. It had been a cold evening and she had plugged in an electric heater
behind the counter to keep warm. She did not remember if the heater was shut off before she
left the market. Ms. Anderson estimated damage to the store contents to be $1,000. The one-story
store had 2,500 square feet of floor space and damage to it was estimated to be $4,000.
During the investigation, the Fire Marshal found a portable heater lying on its side behind the
counter. He determined that the heater ignited a rubber mat on the floor near the cash register.
The automatic shutoff feature on the heater failed to operate when the device tipped over. The
heater was a Heatomatic, model 25, serial number 123666.
Further investigation determined that the hard-wired smoke/heat detector had operated properly and notified the alarm company of the fire. The sprinkler system also had operated properly
- one sprinkler head activated and controlled the fire.
While other firefighters were advancing the hoseline to the seat of the fire, Captain Paul Clarke
(age 37) was injured when he tripped on the hoseline. He suffered a fractured wrist.
Captain Clarke’s injury occurred at 0715. Prior to this incident, Clarke and his crew, all career
firefighters usually assigned to suppression, had responded to two other fires during the night and
five other incidents on their shift. After the fire was extinguished, Captain Clarke was taken to
Mercy Hospital. He returned to work the next week for desk duty. The last company cleared the
scene at 0815. An incident number of 9700967 was assigned for this fire.

5-16

NFIRS 5.0 Self-Study Program
MM

NFIRS–5

YYYY
Delete

FDID

Incident Date

State

Station

Incident Number

Injured Person

1
2

Identification Number

Male
Female

Exposure

Change

Career
Volunteer

1
2

Fire Service
Casualty

Casualty Number

Casualty Number
First Name

Last Name

Suffix

Age or Date of Birth
Age

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

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

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

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

Activity at time of injury

Cause of Firefighter Injury

Object Involved
in Injury

None

Cause of injury

Primary apparent symptom

Day

Physical Condition Just Prior to Injury

Year

Responses

None

Primary Part of Body Injured

Factor Contributing to Injury

None
Object involved in injury

Contributing factor

Primary injured body part

Where Injury Occurred

1
2
3
4
5
6
7
8
9
0
U

Story Where Injury Occurred

Check this box and enter the story if the
injury occurred inside or on a structure
Story of injury

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

5-17

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

NFIRS 5.0 Self-Study Program

Did protective equipment fail and contribute to the injury?

Yes

Please complete the remainder of this form ONLY if you answer YES.

Protective Equipment Item

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.

Burned

Melted

Fractured, cracked or broken

Punctured

Scratched

Knocked off

Cut or ripped

Trapped steam or hazardous gas

Insufficient insulation

Object fell in or onto equipment item

Failed under impact

Face piece or hose detached

Exhalation valve inoperative or damaged

Harness detached or separated

Regulator failed to operate

Regulator damaged by contact

Problem with admissions valve

Alarm failed to operate

Alarm damaged by contact

Supply cylinder or valve failed to operate

Supply cylinder/valve damaged by contact

Special Equipment

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

Did not fit properly

Not properly serviced or stored prior to use

Not used for designed purpose

Not used as recommended by manufacturer

Other equipment problem

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

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

5-18

Equipment Manufacturer, Model and Serial
Number
Manufacturer

Model

Serial Number
NFIRS–5

Revision 05/01/03

NFIRS 5.0 Self-Study Program

TR100

FDID

YYYY

1997

State

1
2

Usual Assignment
Suppression
EMS
Prevention
Training
Maintenance
Communications
Administration
Fire investigation
Other

Day

Year

Month

1
2
4

Rested
Fatigued
Ill or injured

Fracture
None

Wrist

1
2
3
4
5
6
7
8
9
0
U

J2
1

Story Where Injury Occurred

this box and enter the story if the
X Check
injury occurred inside or on a structure
1 Story of injury
Below grade

Injury occurred outside

Hour

Number of prior responses
during past 24 hours

Minute

Taken To
1
4
5
6
7
0

Not transported

Hospital
Doctor’s office
Morgue/funeral home
Residence
Station or quarters
Other

Activity at Time of Injury

Extinguishing fire/
neutralizing incident

Activity at time of injury

Cause of Firefighter Injury

Slip/trip

Object Involved
in Injury

X None

Factor Contributing to Injury

None

Slippery or
uneven surfaces

Hose,
charged

Object involved in injury

Contributing factor

Primary injured body part

Where Injury Occurred

Year

Other
Undetermined

0 7

0 7 1 5

Cause of injury

Primary Part of Body Injured

Day

1 9 9 7

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

Severity
1
2
3
4
5
6
7

Primary apparent symptom

0
U

Responses

Time of Injury

Physical Condition Just Prior to Injury

Midnight is 0000.

Date and Time of Injury

11
Month

Casualty Number

0 0 1

Date of Injury

In years

Volunteer

Suffix

Date of Birth

037

X Career

1
2

Last Name

Age

Female

Change

Fire Service
Casualty

Casualty Number

Age or Date of Birth

1
2
3
4
5
6
7
8
0

X Male

NFIRS–5

Delete

Exposure

Clarke

First Name

000

Incident Number

Identification Number

Paul

9 7 0 0 9 6 7

Station

Injured Person

013

Incident Date

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

5-19

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

NFIRS 5.0 Self-Study Program

Did protective equipment fail and contribute to the injury?

Yes

Please complete the remainder of this form ONLY if you answer YES.

Protective Equipment Item

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.

Burned

Melted

Fractured, cracked or broken

Punctured

Scratched

Knocked off

Cut or ripped

Trapped steam or hazardous gas

Insufficient insulation

Object fell in or onto equipment item

Failed under impact

Face piece or hose detached

Exhalation valve inoperative or damaged

Harness detached or separated

Regulator failed to operate

Regulator damaged by contact

Problem with admissions valve

Alarm failed to operate

Alarm damaged by contact

Supply cylinder or valve failed to operate

Supply cylinder/valve damaged by contact

Special Equipment

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

Did not fit properly

Not properly serviced or stored prior to use

Not used for designed purpose

Not used as recommended by manufacturer

Other equipment problem

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

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

5-20

Equipment Manufacturer, Model and Serial
Number
Manufacturer

Model

Serial Number
NFIRS–5

Revision 05/01/03

NFIRS 5.0 Self-Study Program

EXERCISE SCENARIO 5-2: Cary Street Fire
Directions: Read the call information in the exercise below. Use the information provided to complete the entire Fire Service
Casualty Module form and the 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 Fire Service Casualty Module again.
The Alberta Fire Department (FDID #92188) received a call for a reported house fire at 5 East
Cary Street, Brunswick, Virginia 23351 on May 1, 2005. The dispatcher assigned the incident
(#5433) to Engine 1, Engine 2, and Truck 1 from Shift A, Station 2. The units received the alarm
at 12:53 p.m. and arrived at the scene at 1:05 p.m. Each piece of apparatus was staffed with four
firefighters.
The owner of the single-family dwelling, Mrs. Christy A. Gordon, said that she was warming her
lunch on the stove when the grease from the pan began to burn. The gas stove was a Whirlpool,
Model RF330PXVN, Serial Number F925888840, Year 2000. The fire spread from the pan to
the curtains. She had fallen asleep upstairs and was alerted when the hardwired smoke detector
activated. The flame damage was confined to the kitchen. The 2,000 square feet, two-story home
was filled with smoke in the other rooms. She called 9-1-1. The firefighters extinguished the
fire and removed smoke from the other rooms. The fire was brought under control at 1:25 p.m.
There was $24,000 fire loss to property and $9,600 content loss. The value of the property was
$161,000 and the content value was $80,400. The last unit cleared the scene at 2:40 p.m. FF1
Adam C. Wallner, Badge No. 224, completed the report after returning to Station No.2. Captain
Tonya S. Gordon, Badge No. 105, was the officer in charge. The fire department keeps records on
the location of all responses. The incident was in Census Tract 501.10, District A12.
Mrs. Gordon, 66-year old, white female, was overcome by smoke in her bedroom. She had problems finding the exit because of the smoke. Her injury occurred at 12:50 p.m. Fire department
personnel treated her at the scene. Her injury was considered minor but since she said that she
felt dizzy, a local EMS provider transported her to the Proctor Medical Hospital for observation.
While investigating the incident, Fire Officer Juan M. Mills, a 36-year old, Hispanic, white male,
slipped on debris located on the first floor and sprained his right ankle. His normal assignment
is investigation. He was injured at 2:15 p.m. and treated at the scene by local EMS provider personnel. For precautions, he was also transported to Proctor Medical Hospital for X-rays. He was
treated by the physician and given the okay to return to work. This was his first response in the
24-hour period. Officer Mills is a career member of the department. His badge number is 317.

5-21

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

5-22

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

5-23

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

5-24

NFIRS 5.0 Self-Study Program
Structure Type

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

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

Number of stories w/significant damage
(25 to 49% flame damage)

None Present

Present

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

Number of stories w/extreme damage
(75 to 100% flame damage)

Detector Power Supply

1
2
3
4
5
6
7
0
U

0
U

Detector Operation

Fire too small to activate

Operated

Complete
Block L5

Failed to operate

Complete
Block L6

Undetermined

Type of Automatic Extinguishing System
Required if fire was within designed range of AES

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

Width in feet

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

Item contributing most to flame spread

K2
Type of material contributing
most to flame spread

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

Presence of Automatic Extinguishing System
None Present
N
Present
1
Complete rest of
Section M
2
Partial System Present
U
Undetermined

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

Number of stories w/minor damage
(1 to 24% flame damage)

Presence of Detectors

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

Main Floor Size

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

1
2
3
4
U

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

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

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

5-25

Revision 01/01/06

NFIRS 5.0 Self-Study Program
MM

Delete
FDID

State

Incident Date

Station

Gender
1
Male

First Name

Age or Date of Birth

Months (for infants)
Age

Date of Birth

Month

Day

Year

Race

0
U

Other, multiracial
Undetermined

Affiliation
1
2
3
0

1
0

Date of Injury

Hispanic or Latino
Non Hispanic or Latino

Cause of Injury
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

Midnight is 0000.

Time of Injury

Escaping
Rescue attempt
Fire control
Return to fire before control
Return to fire after control
Sleeping
Unable to act
Irrational act
Other
Undetermined

Month

Day

Year

Human Factors
Contributing to Injury

Hour

None

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

Civilian
EMS, not fire department
Police
Other

Date and Time of Injury

Casualty
Number

Female

Ethnicity

1
2
3
4
5
6
7
8
0
U

Change

Suffix

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

Activity When Injured

Exposure

Last Name

1
2
3
4
5

Incident Number

Injured Person

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

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

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

Below grade

Story Where Injury Occurred

Story where injury occurred, if
different from M3

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

Primary Area of Body Injured

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

5-26

Revision 01/01/04

NFIRS 5.0 Self-Study Program
MM

NFIRS–5

YYYY
Delete

FDID

Incident Date

State

Station

Incident Number

Injured Person

1
2

Identification Number

Male
Female

Exposure

Change

Career
Volunteer

1
2

Fire Service
Casualty

Casualty Number

Casualty Number
First Name

Last Name

Suffix

Age or Date of Birth
Age

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

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

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

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

Activity at time of injury

Cause of Firefighter Injury

Object Involved
in Injury

None

Cause of injury

Primary apparent symptom

Day

Physical Condition Just Prior to Injury

Year

Responses

None

Primary Part of Body Injured

Factor Contributing to Injury

None
Object involved in injury

Contributing factor

Primary injured body part

Where Injury Occurred

1
2
3
4
5
6
7
8
9
0
U

Story Where Injury Occurred

Check this box and enter the story if the
injury occurred inside or on a structure
Story of injury

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

5-27

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

NFIRS 5.0 Self-Study Program

Did protective equipment fail and contribute to the injury?

Yes

Please complete the remainder of this form ONLY if you answer YES.

Protective Equipment Item

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.

Burned

Melted

Fractured, cracked or broken

Punctured

Scratched

Knocked off

Cut or ripped

Trapped steam or hazardous gas

Insufficient insulation

Object fell in or onto equipment item

Failed under impact

Face piece or hose detached

Exhalation valve inoperative or damaged

Harness detached or separated

Regulator failed to operate

Regulator damaged by contact

Problem with admissions valve

Alarm failed to operate

Alarm damaged by contact

Supply cylinder or valve failed to operate

Supply cylinder/valve damaged by contact

Special Equipment

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

Did not fit properly

Not properly serviced or stored prior to use

Not used for designed purpose

Not used as recommended by manufacturer

Other equipment problem

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

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

5-28

Equipment Manufacturer, Model and Serial
Number
Manufacturer

Model

Serial Number
NFIRS–5

Revision 05/01/03

NFIRS 5.0 Self-Study Program

Fire Service Casualty Module Test
1. The Fire Service Casualty Module is used to report (check all that apply)

(a) fire service injuries or deaths involved with any incident response.

(b) fire service exposures involved with any incident response.

(d) onduty fire service injuries or deaths at the fire station.

2. The protective equipment section of the Fire Service Casualty Module is completed when

(a) protective equipment is worn.

(b) protective equipment was not worn but should have been worn.

(d) protective equipment failed and contributed to the injury.

3. Forcible entry and extinguishing fire are examples of this Fire Service Casualty Module’s data
element.

(a) Usual Assignment.

(b) Where Injury Occurred.

(d) Actions Taken.

4. Smoke inhalation and cut are examples of this Fire Service Casualty Module’s data element.

(a) Factor Contributing to Injury.

(b) Severity.

(d) Actions Taken.

5. This Fire Service Casualty Module data element is helpful in determining the condition of the
firefighter at the time of injury (check all that apply).

(a) Responses.

(b) Severity.

(d) Activity at Time of Injury.

5-29

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