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pdfNFIRS 5.0 Self-Study Program
Appendix A
A-1
Table of Contents
Basic Module: NFIRS-1, Scenario 1-2 Answers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A-3
Fire Module: NFIRS-2, Scenario 2-2 Answers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A-6
Structure Fire Module: NFIRS-3, Scenario 3-2 Answers . . . . . . . . . . . . . . . . . . . . . . . . . . . . A-10
Civilian Fire Casualty Module: NFIRS-4, Scenario 4-2 Answers . . . . . . . . . . . . . . . . . . . . . . A-15
Fire Service Casualty Module: NFIRS-5, Scenario 5-2 Answers. . . . . . . . . . . . . . . . . . . . . . . A-21
Emergency Medical Services (EMS) Module: NFIRS-6, Scenario 6-2 Answers . . . . . . . . . . . A-29
Hazardous Materials Module: NFIRS-7, Scenario 7-2 Answers. . . . . . . . . . . . . . . . . . . . . . . A-33
Wildland Fire Module: NFIRS-8, Scenario 8-2 Answers . . . . . . . . . . . . . . . . . . . . . . . . . . . . A-37
Apparatus or Resources Module: NFIRS-9, Scenario 9-2 Answers. . . . . . . . . . . . . . . . . . . . . A-41
Personnel Module: NFIRS-10, Scenario 10-2 Answers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A-47
Arson and Juvenile Firesetter Module: NFIRS-11, Scenario 11-2 Answers. . . . . . . . . . . . . . A-53
NFIRS 5.0 Self-Study Program Appendix A
Basic Module: NFIRS-1
Scenario 1-2 Answers
A-3
NFIRS 5.0 Self-Study Program
A 92188
FDID
B
C
MM
VA
YYYY
01
2002
Station
Prefix
Incident Number
NFIRS–1
Change
Exposure
Basic
No Activity
0501-10
Census Tract
ST
Street or Highway
Street Type
Brunswick
Apt./Suite/Room
Delete
000
Cary
E
5
Number/Milepost
VA
City
23351
State
Suffix
-
ZIP Code
Cross Street, Directions or National Grid, as applicable
Incident Type
X None
Aid Given or Received
Dates and Times
E1
Cooking Fire
Incident Type
D
0 0 0 5 4 3 3
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
113
002
Incident Date
State
Location Type
X
DD
05
Midnight is 0000
Month
Check boxes if
dates are the
same as Alarm
Date.
Day
ALARM always required
05
Alarm
01
Year
Hour
2002
E2
Min
Shifts and Alarms
Local Option
A
1253
Shift or
Platoon
Alarms
A12
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
Additional Action Taken (2)
EMS
Other
Additional Action Taken (3)
Fire Service Cas.–5
EMS–6
HazMat–7
Wildland Fire–8
Apparatus–9
Personnel–10
Arson–11
Personnel
3
0
0
12
0
0
Check box if resource counts include aid
received resources.
H1
Casualties
None
Deaths Injuries
Fire
Service
Civilian
H2
1
2
U
X
0
0
Detector
Required for confined fires.
Detector alerted occupants
Detector did not alert them
Unknown
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
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
J
01 2002
G2
Apparatus
Suppression
Civilian Fire Cas.–4
05
Check this box and skip this block if an
Apparatus or Personnel Module is used.
Primary Action Taken (1)
Fire–2
Structure Fire–3
E3
Special Studies
Local Option
H3
1
2
3
4
5
6
7
8
0
1340
Special
Study Value
Estimated Dollar Losses and Values
LOSSES:
Required for all fires if known.
Optional for non-fires.
Property
$
,
,
Contents
$
,
,
None
0
0
PRE-INCIDENT VALUE: Optional
Property
$
,
,
Contents
$
,
,
X
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.)
X
Special
Study ID#
LAST UNIT CLEARED, required except for wildland fires
Resources
G1
Ventilate
Completed Modules
1305
Controlled
Actions Taken
51
01 2002
CONTROLLED optional, except for wildland fires
Their
State
Their Incident Number
F
05
Arrival
I
Mixed Use
Property
10
20
33
40
51
53
58
59
60
63
65
00
X
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
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
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
A-4
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
K1
Local Option
Business Name (if applicable)
Check this box if same
address as incident
Location (Section B).
Then skip the three
duplicate address
lines.
X
Area Code
Christy
First Name
Mr., Ms., Mrs.
Phone Number
Gordon
MI
Last Name
Suffix
East Cary Street
5
Number
Prefix
Street or Highway
Street Type
Suffix
Brunswick
Post Office Box
VA
Apt./Suite/Room
City
23351
State
ZIP Code
More people involved? Check this box and attach Supplemental Forms (NFIRS–1S) as necessary.
as person involved?
X Same
Then check this box and skip
Owner
K2
Local Option
Check this box if same
address as incident
Location (Section B).
Then skip the three
duplicate address
lines.
the rest of this block.
Mr., Ms., Mrs.
Business Name (if applicable)
First Name
Number
MI
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:
L
Local Option
Mrs. Christy A. Gordon was warming her lunch on the stove
when the grease from the pan began to burn.
Fire Module Required?
Check the box that applies and then complete the Fire Module
based on Incident Type, as follows:
Complete Fire & Structure Modules
Complete Fire Module &
Section I, Structure Module
Basic Module Only
Confined 113–118
Complete Fire Module
Mobile property 120–123
Complete Fire Module
Vehicle 130–138
Complete Fire or Wildland Module
Vegetation 140–143
Outside rubbish fire 150–155 Basic Module Only
Complete Fire or Wildland Module
Special outside fire 160
Special outside fire 161–163 Complete Fire Module
Complete Fire or Wildland Module
Crop fire 170–173
Buildings 111
Special structure 112
ITEMS WITH A
MUST ALWAYS BE COMPLETED!
More remarks? Check this box and attach Supplemental Forms (NFIRS–1S) as necessary.
M
Authorization
Check box if
same as
Officer in
charge.
105
Officer in charge ID
Tonya Gordon
Captain
Position or rank
Signature
224
Member making report ID
Adam Wallner
05
Assignment
Month
Assignment
Month
FF1
Signature
Position or rank
A-5
05
01
Day
01
Day
2002
Year
2002
Year
NFIRS 5.0 Self-Study Program Appendix A
Fire Module: NFIRS-2
Scenario 2-2 Answers
A-6
NFIRS 5.0 Self-Study Program
A 92188
FDID
B
DD
05
YYYY
03
2002
Station
Delete
000
Incident Number
Prefix
Exposure
Basic
No Activity
0501-10
Census Tract
ST
Street or Highway
Street Type
Brunswick
Apt./Suite/Room
NFIRS–1
Change
I-95
MM 73
Number/Milepost
VA
City
23351
State
Near Exit 2B
Suffix
-
ZIP Code
Cross Street, Directions or National Grid, as applicable
Incident Type
X
Aid Given or Received
Dates and Times
E1
Passenger Vehicle
None
Midnight is 0000
Month
Check boxes if
dates are the
same as Alarm
Date.
Incident Type
D
0 0 0 5 4 5 5
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
131
002
Incident Date
State
Location Type
X
C
MM
VA
Day
Year
ALARM always required
05
Alarm
03
Hour
2002
E2
Min
Shifts and Alarms
Local Option
C
2358
Shift or
Platoon
Alarms
A05
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
Controlled
Last Unit
Cleared
Actions Taken
11
Additional Action Taken (2)
EMS
Other
Additional Action Taken (3)
Civilian Fire Cas.–4
Fire Service Cas.–5
EMS–6
HazMat–7
Wildland Fire–8
Apparatus–9
Personnel–10
Arson–11
05
05
Personnel
2
0
0
6
0
0
Check box if resource counts include aid
received resources.
Casualties
X
None
Deaths Injuries
Fire
Service
Civilian
H2
1
2
U
Special Studies
Local Option
Detector
Required for confined fires.
Detector alerted occupants
Detector did not alert them
Unknown
H3
1
2
3
4
5
6
7
8
0
0010
04 2002
G2
Apparatus
Suppression
H1
E3
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.
Primary Action Taken (1)
Fire–2
Structure Fire–3
0004
04 2002
Resources
G1
Extinguish
Completed Modules
04 2002
CONTROLLED optional, except for wildland fires
Their
State
Their Incident Number
F
05
Arrival
0035
Special
Study Value
Estimated Dollar Losses and Values
LOSSES:
Required for all fires if known.
Optional for non-fires.
Property
$
,
Contents
$
,
None
26 , 000
0
,
PRE-INCIDENT VALUE: Optional
Property
$
,
,
Contents
$
,
,
X
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.)
I
Mixed Use
Property
10
20
33
40
51
53
58
59
60
63
65
00
X
Not mixed
Assembly use
Education use
Medical use
Residential use
Row of stores
Enclosed mall
Business & residential
Office use
Industrial use
Military use
Farm use
Other mixed use
Property Use
None
Structures
Church, place of worship
131
Restaurant or cafeteria
161
Bar/tavern or nightclub
162
Elementary school, kindergarten
213
High school, junior high
215
College, adult education
241
Nursing home
311
Hospital
331
341
342
361
419
429
439
449
459
464
519
Clinic, clinic-type infirmary
Doctor/dentist office
Prison or jail, not juvenile
1- or 2-family dwelling
Multifamily dwelling
Rooming/boarding house
Commercial hotel or motel
Residential, board and care
Dormitory/barracks
Food and beverage sales
539
571
579
599
615
629
700
819
882
891
Household goods, sales, repairs
Gas or service station
Motor vehicle/boat sales/repairs
Business office
Electric-generating plant
Laboratory/science laboratory
Manufacturing plant
Livestock/poultry storage (barn)
Non-residential parking garage
Warehouse
Outside
Playground or park
124
Crops or orchard
655
Forest (timberland)
669
Outdoor storage area
807
Dump or sanitary landfill
919
Open land or field
931
936
938
946
951
960
961
962
Vacant lot
Graded/cared for plot of land
Lake, river, stream
Railroad right-of-way
Other street
Highway/divided highway
Residential street/driveway
981
984
Construction site
Industrial plant yard
J
X
A-7
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
K1
414
Local Option
Business Name (if applicable)
Check this box if same
address as incident
Location (Section B).
Then skip the three
duplicate address
lines.
Area Code
Robert
X
L
First Name
Mr., Ms., Mrs.
432
Anderson
MI
Last Name
Suffix
Second
630
Number
Prefix
0 9 8 7
Phone Number
Ave
Street or Highway
Street Type
Suffix
Jarrett
Post Office Box
NC
Apt./Suite/Room
City
24501
State
ZIP Code
More people involved? Check this box and attach Supplemental Forms (NFIRS–1S) as necessary.
as person involved?
X Same
Then check this box and skip
Owner
K2
Local Option
Check this box if same
address as incident
Location (Section B).
Then skip the three
duplicate address
lines.
the rest of this block.
Mr., Ms., Mrs.
Business Name (if applicable)
First Name
Number
MI
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:
L
Local Option
He said that his front seat caught on fire from a cigarette.
He was drowsy from a prescription drug that he took.
Fire Module Required?
Check the box that applies and then complete the Fire Module
based on Incident Type, as follows:
Complete Fire & Structure Modules
Complete Fire Module &
Section I, Structure Module
Basic Module Only
Confined 113–118
Complete Fire Module
Mobile property 120–123
Complete Fire Module
Vehicle 130–138
Complete Fire or Wildland Module
Vegetation 140–143
Outside rubbish fire 150–155 Basic Module Only
Complete Fire or Wildland Module
Special outside fire 160
Special outside fire 161–163 Complete Fire Module
Complete Fire or Wildland Module
Crop fire 170–173
Buildings 111
Special structure 112
ITEMS WITH A
MUST ALWAYS BE COMPLETED!
More remarks? Check this box and attach Supplemental Forms (NFIRS–1S) as necessary.
M
Authorization
Check box if
same as
Officer in
charge.
100
Officer in charge ID
Ernest Greene
Captain
Position or rank
Signature
230
Member making report ID
Steve LaCivita
05
Assignment
Month
Assignment
Month
FF1
Signature
Position or rank
A-8
05
04
Day
04
Day
2002
Year
2002
Year
NFIRS 5.0 Self-Study Program
A
92188
FDID
B
MM
VA
DD
05
YYYY
03
2002
002
Incident Date
State
Station
Property Details
C
0
B1
X Not Residential
0 0 0 5 4 5 5
Incident Number
On-Site Materials
or Products
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
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
Estimated number of residential living units in
building of origin whether or not all units
became involved
0
B2
Buildings not involved
Number of buildings involved
B3
0
,
X None
Less than one acre
Acres burned (outside fires)
On-site material (3)
Ignition
D
Operator/passenger area
D1 8 1
Area of fire origin
61
D2 Heat
source
Cigarette
D3 2 1
Upholstered sofa, chair,...
Item first ignited
1
Check box if fire spread was
confined to object of origin.
1
2
3
4
5
U
Type of material first ignited
Skip to
Section G
Check box if this is an exposure report.
E3
Factors Contributing to Ignition
Abandoned or discarded
materials or products
11
1 Asleep
2 X Possibly impaired by
alcohol or drugs
3 Unattended person
4 Possibly mentally disabled
5 Physically disabled
None
6 Multiple persons involved
Estimated age of
person involved
Factor contributing to ignition (1)
1
X None
Equipment Power Source
F2
Age was a factor
7
Required only if item first
ignited code is 00 or <70
Equipment Involved in Ignition
None
Intentional
Unintentional
Failure of equipment or heat source
Act of nature
Cause under investigation
Cause undetermined after investigation
Factor contributing to ignition (2)
F1
Human Factors
Contributing to Ignition
Check all applicable boxes
X
E2
7 1 Fabric, fiber, cotton,...
D4
Cause of Ignition
E1
Fire
Change
Exposure
None
NFIRS–2
Delete
000
G
2
Male
Fire Suppression Factors
Female
X None
Enter up to three codes.
If equipment was not involved, skip to
Section G
Equipment Power Source
Equipment Involved
Equipment Portability
F3
Brand
Model
Serial #
H1
Mobile Property Involved
1
Not involved in ignition, but burned
3
None
H2
Stationary
Fire suppression factor (2)
Fire suppression factor (3)
Mobile Property Type and Make
11
Passenger Car
Mobile property type
Involved in ignition, but did not burn
X
Portable
2
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
2
1
Fire suppression factor (1)
FO
Involved in ignition and burned
Ford
Mobile property make
1999
Explorer
Mobile property model
A C Z 5 8 6
License Plate Number
Year
VA
State
Local Use
Pre-Fire Plan Available
Some of the information presented in this report may be
based upon reports from other agencies:
Arson report attached
Police report attached
Coroner report attached
Other reports attached
1FBEU54XABC45634
VIN
Structure fire? Please be sure to complete the Structure Fire form (NFIRS–3).
NFIRS–2 Revision 01/01/05
A-9
NFIRS 5.0 Self-Study Program Appendix A
Structure Fire Module:
NFIRS-3
Scenario 3-2 Answers
A-10
NFIRS 5.0 Self-Study Program
A 92188
FDID
B
C
MM
VA
YYYY
01
2005
Station
Prefix
Incident Number
NFIRS–1
Change
Exposure
Basic
No Activity
5011-12
Census Tract
ST
Street or Highway
Street Type
Brunswick
Apt./Suite/Room
Delete
000
Cary
E
5
Number/Milepost
VA
City
23351
State
Suffix
-
ZIP Code
Cross Street, Directions or National Grid, as applicable
Incident Type
Midnight is 0000
Month
Check boxes if
dates are the
same as Alarm
Date.
X None
Aid Given or Received
Dates and Times
E1
Building Fires
Incident Type
D
0 0 0 5 4 3 3
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
111
002
Incident Date
State
Location Type
X
DD
05
Day
ALARM always required
05
Alarm
01
Year
Hour
2005
E2
Min
Shifts and Alarms
Local Option
A
1253
Shift or
Platoon
Alarms
A12
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
Controlled
Last Unit
Cleared
Actions Taken
11
Suppression
Additional Action Taken (2)
EMS
Other
Additional Action Taken (3)
Civilian Fire Cas.–4
Fire Service Cas.–5
EMS–6
HazMat–7
Wildland Fire–8
Apparatus–9
Personnel–10
Arson–11
05
H1
Casualties
X
None
Deaths Injuries
Fire
Service
Civilian
H2
1
2
U
X
Special Studies
Local Option
Detector
Required for confined fires.
Detector alerted occupants
Detector did not alert them
Unknown
341
342
361
419
429
439
449
459
464
519
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
H3
1
2
3
4
5
6
7
8
0
1325
01 2005
G2
Personnel
3
0
0
12
0
0
Check box if resource counts include aid
received resources.
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
J
05
Apparatus
Ventilate
Fire–2
Structure Fire–3
E3
1440
Special
Study Value
Estimated Dollar Losses and Values
LOSSES:
Required for all fires if known.
Optional for non-fires.
Property
$
,
Contents
$
,
24 , 000
9 , 600
None
PRE-INCIDENT VALUE: Optional
Property
$
Contents
$
X
Hazardous Materials Release
161 , 000
, 80 , 400
,
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.)
X
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.
Extinguish
Completed Modules
1305
01 2005
Resources
G1
Primary Action Taken (1)
51
01 2005
CONTROLLED optional, except for wildland fires
Their
State
Their Incident Number
F
05
Arrival
I
Mixed Use
Property
10
20
33
40
51
53
58
59
60
63
65
00
X
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
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
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
A-11
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
K1
Local Option
Business Name (if applicable)
Check this box if same
address as incident
Location (Section B).
Then skip the three
duplicate address
lines.
X
Area Code
Christy
A
First Name
Mr., Ms., Mrs.
Phone Number
Gordon
MI
Last Name
Suffix
East Cary
5
Number
Prefix
ST
Street or Highway
Street Type
Suffix
Brunswick
Post Office Box
VA
Apt./Suite/Room
City
23351
State
ZIP Code
More people involved? Check this box and attach Supplemental Forms (NFIRS–1S) as necessary.
as person involved?
X Same
Then check this box and skip
Owner
K2
Local Option
Check this box if same
address as incident
Location (Section B).
Then skip the three
duplicate address
lines.
the rest of this block.
Mr., Ms., Mrs.
Business Name (if applicable)
First Name
Number
MI
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:
L
Local Option
Mrs. Christy A. Gordon was warming her lunch on the stove
when the grease from the pan began to burn.
Fire Module Required?
Check the box that applies and then complete the Fire Module
based on Incident Type, as follows:
Complete Fire & Structure Modules
Complete Fire Module &
Section I, Structure Module
Basic Module Only
Confined 113–118
Complete Fire Module
Mobile property 120–123
Complete Fire Module
Vehicle 130–138
Complete Fire or Wildland Module
Vegetation 140–143
Outside rubbish fire 150–155 Basic Module Only
Complete Fire or Wildland Module
Special outside fire 160
Special outside fire 161–163 Complete Fire Module
Complete Fire or Wildland Module
Crop fire 170–173
Buildings 111
Special structure 112
ITEMS WITH A
MUST ALWAYS BE COMPLETED!
More remarks? Check this box and attach Supplemental Forms (NFIRS–1S) as necessary.
M
Authorization
Check box if
same as
Officer in
charge.
105
Officer in charge ID
Tonya Gordon
Signature
224
Member making report ID
Captain
Position or rank
Adam Wallner
Signature
05
Assignment
Month
Assignment
Month
FF1
Position or rank
A-12
05
01
Day
01
Day
2005
Year
2005
Year
NFIRS 5.0 Self-Study Program
A
92188
FDID
B
MM
DD
05
VA
YYYY
01
002
2005
Incident Date
State
Station
Property Details
C
1
B1
Not Residential
0 0 0 5 4 3 3
Incident Number
On-Site Materials
or Products
None
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
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
Estimated number of residential living units in
building of origin whether or not all units
became involved
1
B2
Buildings not involved
Number of buildings involved
B3
None
,
Less than one acre
Acres burned (outside fires)
On-site material (3)
D
Ignition
E1
D1 2 4 Cooking area, kitchen
Area of fire origin
D2
8 1 Heat from direct flame
Heat source
1
2
3
4
5
U
D4
confined to object of origin.
Skip to
Section G
Check box if this is an exposure report.
X
Intentional
Unintentional
Failure of equipment or heat source
Act of nature
Cause under investigation
Cause undetermined after investigation
E3
1
2
Equipment unattended
None
F2
1
6 4 6 Range with or without oven
Equipment Involved
Serial #
Whirlpool
RF330PXVN
F925888840
Year
2000
Brand
Model
H1
Mobile Property Involved
1
Not involved in ignition, but burned
2
Involved in ignition, but did not burn
3
Involved in ignition and burned
Equipment Power Source
Equipment Portability
Fire Suppression Factors
Female
X None
Enter up to three codes.
2
X
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.
H2
Fire suppression factor (1)
Portable
1
None
2
Male
Equipment Power Source
F3
X
G
2 1 Natural Gas or other
If equipment was not involved, skip to
Section G
Age was a factor
Estimated age of
person involved
Required only if item first
ignited code is 00 or <70
Equipment Involved in Ignition
None
Possibly impaired by
alcohol or drugs
Unattended person
Possibly mentally disabled
Physically disabled
Multiple persons involved
7
Factor contributing to ignition (1)
Factor contributing to ignition (2)
F1
Human Factors
Contributing to Ignition
X Asleep
3
4
5
None
6
Factors Contributing to Ignition
53
2 7 Cooking oil
Type of material first ignited
Cause of Ignition
Check all applicable boxes
D3 7 6 Cooking materials, incl E2
Item first ignited
Check box if fire spread was
1
Fire
Change
Exposure
X
NFIRS–2
Delete
0
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
A-13
NFIRS 5.0 Self-Study Program
Structure Type
I1
If fire was in an enclosed building or a
portable/mobile structure, complete the
rest of this form.
X Enclosed building
1
2
3
4
5
6
7
8
0
Portable/mobile structure
Open structure
Air-supported structure
Tent
Open platform (e.g., piers)
Underground structure (work areas)
Connective structure (e.g., fences)
Other type of structure
Fire Origin
J1
1
I2
Building Status
1
2
3
4
5
6
7
0
U
Under construction
Occupied & operating
Idle, not routinely used
Under major renovation
Vacant and secured
Vacant and unsecured
Being demolished
Other
Undetermined
J3
Below grade
Story of
fire origin
Fire Spread
J2
2
3
4
5
If fire spread was confined to object of origin,
do not check a box (Ref. Block D3, Fire Module).
X Confined to room of origin
Confined to floor of origin
Confined to building of origin
Beyond building of origin
Presence of Detectors
L1
1
U
None Present
X
Skip to
Section M
Present
Undetermined
Detector Type
L2
X
1
2
3
4
5
0
U
M1
Smoke
Heat
Combination smoke and heat
Sprinkler, water flow detection
More than one type present
Other
Undetermined
1
2
3
4
5
6
7
0
U
0
Number of stories w/heavy damage
(50 to 74% flame damage)
0
Number of stories w/extreme damage
(75 to 100% flame damage)
Detector Power Supply
Battery only
Hardwire only
Plug-in
Hardwire with battery
Plug-in with battery
Mechanical
Multiple detectors & power
supplies
Other
Undetermined
Detector Operation
1
Fire too small to activate
X
Operated
Complete
Block L5
3
Failed to operate
Complete
Block L6
U
Undetermined
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
M3
K
Width in feet
Check if no flame spread OR if
same as Material First Ignited (Block D4,
Fire Module) OR if unable to determine.
K1
Skip to
Section L
Item contributing most to flame spread
K2
Type of material contributing
most to flame spread
1
2
Detector Effectiveness
X
3
4
U
L6
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
Number of Sprinkler
Heads Operating
Required if system operated
Required only if item
contributing code is 00 or <70.
Required if detector operated.
Operated/effective (go to M4)
Operated/not effective (go to M4)
Fire too small to activate
Failed to operate (go to M5)
Other
Undetermined
M4
,
BY
Type of Material Contributing Most
to Flame Spread
M5
Required if fire was within designed range
1
2
3
4
0
U
0 0 0
,
Length in feet
L5
L4
2
,
Total number of stories
below grade
Number of stories w/significant damage
(25 to 49% flame damage)
0
U
2
,
OR
0
X
NFIRS–3
Structure
Fire
Total square feet
0
Number of stories w/minor damage
(1 to 24% flame damage)
Type of Automatic Extinguishing System
Required if fire was within designed range of AES
2
Total number of stories at or
above grade
1
1
2
3
4
5
6
7
Main Floor Size
I4
Count the roof as part of the
highest story.
Count the roof as part of the highest story.
Presence of Automatic Extinguishing System
N X None Present
Present
1
Complete rest of
Section M
2
Partial System Present
U
Undetermined
M2
Building
Height
Number of Stories Damaged by Flame
L3
(In area of the fire)
N
X
I3
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
A-14
Revision 01/01/06
NFIRS 5.0 Self-Study Program Appendix A
Civilian Fire Casualty
Module: NFIRS-4
Scenario 4-2 Answers
A-15
NFIRS 5.0 Self-Study Program
A 92188
FDID
B
C
MM
VA
YYYY
01
2005
Station
Prefix
Incident Number
NFIRS–1
Change
Exposure
Basic
No Activity
0501-10
Census Tract
ST
Street or Highway
Street Type
Brunswick
Apt./Suite/Room
Delete
000
Cary
E
5
Number/Milepost
VA
City
23351
State
Suffix
-
ZIP Code
Cross Street, Directions or National Grid, as applicable
Incident Type
Building Fires
Incident Type
D
0 0 0 5 4 3 3
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
111
002
Incident Date
State
Location Type
X
DD
05
X None
Aid Given or Received
Dates and Times
E1
Midnight is 0000
Month
Check boxes if
dates are the
same as Alarm
Date.
Day
ALARM always required
05
Alarm
01
Year
Hour
2005
E2
Min
Shifts and Alarms
Local Option
A
1253
Shift or
Platoon
Alarms
A12
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
Controlled
Last Unit
Cleared
Actions Taken
11
Suppression
Additional Action Taken (2)
EMS
Other
Additional Action Taken (3)
Civilian Fire Cas.–4
Fire Service Cas.–5
EMS–6
HazMat–7
Wildland Fire–8
Apparatus–9
Personnel–10
Arson–11
01 2005
H1
Casualties
None
Deaths Injuries
Fire
Service
Civilian
H2
1
2
U
X
E3
Special Studies
Local Option
0
0
0
1
Detector
Required for confined fires.
Detector alerted occupants
Detector did not alert them
Unknown
341
342
361
419
429
439
449
459
464
519
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
H3
1
2
3
4
5
6
7
8
0
1325
01 2005
G2
Personnel
3
0
0
12
0
0
Check box if resource counts include aid
received resources.
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
J
05
Apparatus
Ventilate
Fire–2
Structure Fire–3
05
Check this box and skip this block if an
Apparatus or Personnel Module is used.
Extinguish
Completed Modules
1305
1440
Special
Study Value
Estimated Dollar Losses and Values
LOSSES:
Required for all fires if known.
Optional for non-fires.
Property
$
,
Contents
$
,
24 , 000
9 , 600
None
PRE-INCIDENT VALUE: Optional
Property
$
Contents
$
X
Hazardous Materials Release
161 , 000
, 80 , 400
,
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.)
X
Special
Study ID#
LAST UNIT CLEARED, required except for wildland fires
Resources
G1
Primary Action Taken (1)
51
01 2005
CONTROLLED optional, except for wildland fires
Their
State
Their Incident Number
F
05
Arrival
I
Mixed Use
Property
10
20
33
40
51
53
58
59
60
63
65
00
X
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
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
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
A-16
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
K1
Local Option
Business Name (if applicable)
Check this box if same
address as incident
Location (Section B).
Then skip the three
duplicate address
lines.
X
Area Code
Christy
A
First Name
Mr., Ms., Mrs.
Phone Number
Gordon
MI
Last Name
Suffix
East Cary
5
Number
Prefix
ST
Street or Highway
Street Type
Suffix
Brunswick
Post Office Box
VA
Apt./Suite/Room
City
23351
State
ZIP Code
More people involved? Check this box and attach Supplemental Forms (NFIRS–1S) as necessary.
as person involved?
X Same
Then check this box and skip
Owner
K2
Local Option
Check this box if same
address as incident
Location (Section B).
Then skip the three
duplicate address
lines.
the rest of this block.
Mr., Ms., Mrs.
Business Name (if applicable)
First Name
Number
MI
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:
L
Local Option
Mrs. Christy A. Gordon was warming her lunch on the stove
when the grease from the pan began to burn.
Fire Module Required?
Check the box that applies and then complete the Fire Module
based on Incident Type, as follows:
Complete Fire & Structure Modules
Complete Fire Module &
Section I, Structure Module
Basic Module Only
Confined 113–118
Complete Fire Module
Mobile property 120–123
Complete Fire Module
Vehicle 130–138
Complete Fire or Wildland Module
Vegetation 140–143
Outside rubbish fire 150–155 Basic Module Only
Complete Fire or Wildland Module
Special outside fire 160
Special outside fire 161–163 Complete Fire Module
Complete Fire or Wildland Module
Crop fire 170–173
Buildings 111
Special structure 112
ITEMS WITH A
MUST ALWAYS BE COMPLETED!
More remarks? Check this box and attach Supplemental Forms (NFIRS–1S) as necessary.
M
Authorization
Check box if
same as
Officer in
charge.
105
Officer in charge ID
Tonya Gordon
Signature
224
Member making report ID
Captain
Position or rank
Adam Wallner
Signature
05
Assignment
Month
Assignment
Month
FF1
Position or rank
A-17
05
01
Day
01
Day
2005
Year
2005
Year
NFIRS 5.0 Self-Study Program
A
92188
FDID
B
MM
05
VA
DD
YYYY
01
2005
Incident Date
State
Station
Property Details
C
1
B1
0 0 0 5 4 3 3
002
Not Residential
Incident Number
On-Site Materials
or Products
None
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
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
Estimated number of residential living units in
building of origin whether or not all units
became involved
1
B2
Buildings not involved
Number of buildings involved
B3
None
,
Less than one acre
Acres burned (outside fires)
On-site material (3)
D
Ignition
E1
D1 2 4 Cooking area, kitchen
Area of fire origin
D2
8 1 Heat from direct flame
Heat source
1
2
3
4
5
U
D4
confined to object of origin.
Skip to
Section G
Check box if this is an exposure report.
X
Intentional
Unintentional
Failure of equipment or heat source
Act of nature
Cause under investigation
Cause undetermined after investigation
Factors Contributing to Ignition
5 3 Equipment unattended
2 7 Cooking oil, transorme
Type of material first ignited
Cause of Ignition
E3
1
2
None
1
6 4 6 Range with or without oven
Equipment Involved
Serial #
Whirlpool
RF330PXVN
F925888840
Year
2000
Brand
Model
H1
Mobile Property Involved
1
Not involved in ignition, but burned
2
Involved in ignition, but did not burn
3
Involved in ignition and burned
Equipment Power Source
2
Male
Fire Suppression Factors
Female
X None
Enter up to three codes.
Equipment Power Source
F3
Equipment Portability
2
X
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.
H2
Fire suppression factor (1)
Portable
1
None
G
2 1 Natural Gas or other
If equipment was not involved, skip to
Section G
Age was a factor
Estimated age of
person involved
Required only if item first
ignited code is 00 or <70
F2
Possibly impaired by
alcohol or drugs
Unattended person
Possibly mentally disabled
Physically disabled
Multiple persons involved
7
Factor contributing to ignition (1)
Equipment Involved in Ignition
None
X Asleep
3
4
5
None
6
Factor contributing to ignition (2)
F1
Human Factors
Contributing to Ignition
Check all applicable boxes
D3 7 6 Cooking materials, incl E2
Item first ignited
Check box if fire spread was
1
Fire
Change
Exposure
X
NFIRS–2
Delete
0
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
A-18
NFIRS 5.0 Self-Study Program
Structure Type
I1
If fire was in an enclosed building or a
portable/mobile structure, complete the
rest of this form.
X Enclosed building
1
2
3
4
5
6
7
8
0
Portable/mobile structure
Open structure
Air-supported structure
Tent
Open platform (e.g., piers)
Underground structure (work areas)
Connective structure (e.g., fences)
Other type of structure
Fire Origin
J1
1
I2
Building Status
1
2
3
4
5
6
7
0
U
Under construction
Occupied & operating
Idle, not routinely used
Under major renovation
Vacant and secured
Vacant and unsecured
Being demolished
Other
Undetermined
J3
Below grade
Story of
fire origin
Fire Spread
J2
2
3
4
5
If fire spread was confined to object of origin,
do not check a box (Ref. Block D3, Fire Module).
X Confined to room of origin
Confined to floor of origin
Confined to building of origin
Beyond building of origin
Presence of Detectors
L1
1
U
X
Skip to
Section M
Present
Undetermined
Detector Type
L2
1
2
3
4
5
0
U
None Present
X
M1
Smoke
Heat
Combination smoke and heat
Sprinkler, water flow detection
More than one type present
Other
Undetermined
1
2
3
4
5
6
7
0
U
Wet-pipe sprinkler
Dry-pipe sprinkler
Other sprinkler system
Dry chemical system
Foam system
Halogen-type system
Carbon dioxide (CO2) system
Other special hazard system
Undetermined
0
1
Number of stories w/significant damage
(25 to 49% flame damage)
0
Number of stories w/heavy damage
(50 to 74% flame damage)
0
Number of stories w/extreme damage
(75 to 100% flame damage)
Detector Power Supply
L4
Detector Operation
1
Fire too small to activate
X
Operated
Complete
Block L5
3
Failed to operate
Complete
Block L6
U
Undetermined
2
M3
K
Check if no flame spread OR if
same as Material First Ignited (Block D4,
Fire Module) OR if unable to determine.
K1
Skip to
Section L
Item contributing most to flame spread
K2
Type of material contributing
most to flame spread
1
2
Detector Effectiveness
X
3
4
U
L6
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
Number of Sprinkler
Heads Operating
Required if system operated
Required only if item
contributing code is 00 or <70.
Required if detector operated.
Operated/effective (go to M4)
Operated/not effective (go to M4)
Fire too small to activate
Failed to operate (go to M5)
Other
Undetermined
M4
Width in feet
Type of Material Contributing Most
to Flame Spread
M5
Required if fire was within designed range
1
2
3
4
0
U
,
BY
Length in feet
L5
Battery only
Hardwire only
Plug-in
Hardwire with battery
Plug-in with battery
Mechanical
Multiple detectors & power
supplies
Other
Undetermined
0
U
1 , 0 0 0
,
Total square feet
,
Total number of stories
below grade
0
X
NFIRS–3
Structure
Fire
OR
Number of stories w/minor damage
(1 to 24% flame damage)
Type of Automatic Extinguishing System
Required if fire was within designed range of AES
2
Total number of stories at or
above grade
1
1
2
3
4
5
6
7
Main Floor Size
I4
Count the roof as part of the
highest story.
Count the roof as part of the highest story.
Presence of Automatic Extinguishing System
N X None Present
Present
1
Complete rest of
Section M
2
Partial System Present
U
Undetermined
M2
Building
Height
Number of Stories Damaged by Flame
L3
(In area of the fire)
N
X
I3
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
A-19
Revision 01/01/06
NFIRS 5.0 Self-Study Program
VA
A 92188
FDID
State
MM
DD
05
YYYY
01
2005
Incident Date
MI
Age or Date of Birth
66
Months (for infants)
Age
E1
1
2
3
4
5
Date of Birth
1
Year
F
Black, African American
Am. Indian, Alaska Native
Asian
Native Hawaiian, Other
Pacific Islander
1
0
X
Hispanic or Latino
Non Hispanic or Latino
1
2
3
4
5
6
7
8
0
U
Escaping
Rescue attempt
Fire control
Return to fire before control
Return to fire after control
Sleeping
Unable to act
Irrational act
Other
Undetermined
X
M1
05
Month
Time of Injury
01
Day
1 2 5 0
Hour
K
None
23
Check all applicable boxes
X
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
In area of origin and not involved
M3
1
2
3
4
5
U
X
Minor
Moderate
Severe
Life threatening
Death
Undetermined
Minute
Factors Contributing
to Injury
None
Vision blocked or impaired by smoke
Contributing factor (1)
63
Improper use of cooking equipment
Contributing factor (2)
Contributing factor (3)
Story at Start of Incident
Complete ONLY if injury occurred INSIDE
Not in area of origin and not involved
X 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
2
Story at start of incident
M4
M2
X
2005
Year
Location at Time of Incident
1
2
3
4
0
U
Midnight is 0000.
Date and Time of Injury
Severity
H
Civilian
EMS, not fire department
Police
Other
Enter up to three contributing factors
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
Activity When Injured
X
1
2
3
0
Human Factors
Contributing to Injury
J
X Exposed to fire products including flame
Affiliation
Date of Injury
Ethnicity
E2
L
G
Other, multiracial
Undetermined
Cause of Injury
2
3
4
5
6
7
8
9
0
U
1
Casualty Number
Suffix
Race
0
U
Day
Casualty
Number
C
X Female
Last Name
X White
OR
Month
Change
Gordon
First Name
D
2
NFIRS–4
Civilian Fire
Casualty
Delete
Exposure
Gender
1
Male
Christy
0
Incident Number
Station
Injured Person
B
I
0 0 0 5 4 3 3
002
Story Where Injury Occurred
Story where injury occurred, if
different from M3
M5
Below grade
2
Below grade
Specific Location at Time of Injury
Complete ONLY if casualty NOT in area of origin
Skip to
Block M5
21
Bedroom - < 5 persons; incl
Specific location at time of injury
Primary Apparent Symptom
N
01
11
12
21
33
96
98
X
Smoke only, asphyxiation
Burns and smoke inhalation
Burns only
Cut, laceration
Strain or sprain
Shock
Pain only
Look up a code only if the symptom is NOT found above
Primary apparent symptom
O
Primary Area of Body Injured
P
Disposition
X Transported to emergency care facility
1
2
3
4
5
6
7
8
9
X
Head
Neck and shoulder
Thorax
Abdomen
Spine
Upper extremities
Lower extremities
Internal
Multiple body parts
Remarks
Local option
NFIRS–4
A-20
Revision 01/01/04
NFIRS 5.0 Self-Study Program Appendix A
Fire Service Casualty
Module: NFIRS-5
Scenario 5-2 Answers
A-21
NFIRS 5.0 Self-Study Program
A 92188
FDID
B
C
MM
VA
YYYY
01
2005
Station
Prefix
Incident Number
NFIRS–1
Change
Exposure
Basic
No Activity
0501-10
Census Tract
ST
Street or Highway
Street Type
Brunswick
Apt./Suite/Room
Delete
000
Cary
E
5
Number/Milepost
VA
City
23351
State
Suffix
-
ZIP Code
Cross Street, Directions or National Grid, as applicable
Incident Type
Building Fires
Incident Type
D
0 0 0 5 4 3 3
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
111
002
Incident Date
State
Location Type
X
DD
05
X
Aid Given or Received
None
Dates and Times
E1
Midnight is 0000
Month
Check boxes if
dates are the
same as Alarm
Date.
Day
ALARM always required
05
Alarm
01
Year
Hour
2005
E2
Min
Shifts and Alarms
Local Option
A
1253
Shift or
Platoon
Alarms
A12
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
Controlled
Last Unit
Cleared
Actions Taken
11
Suppression
Additional Action Taken (2)
EMS
Other
Additional Action Taken (3)
Civilian Fire Cas.–4
Fire Service Cas.–5
EMS–6
HazMat–7
Wildland Fire–8
Apparatus–9
Personnel–10
Arson–11
01 2005
H1
Casualties
None
Deaths Injuries
Fire
Service
Civilian
H2
1
2
U
X
E3
Special Studies
Local Option
1
1
0
0
Detector
Required for confined fires.
Detector alerted occupants
Detector did not alert them
Unknown
341
342
361
419
429
439
449
459
464
519
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
H3
1
2
3
4
5
6
7
8
0
1325
01 2005
G2
Personnel
3
0
0
12
0
0
Check box if resource counts include aid
received resources.
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
J
05
Apparatus
Ventilate
Fire–2
Structure Fire–3
05
Check this box and skip this block if an
Apparatus or Personnel Module is used.
Extinguish
Completed Modules
1305
1440
Special
Study Value
Estimated Dollar Losses and Values
LOSSES:
Required for all fires if known.
Optional for non-fires.
Property
$
,
Contents
$
,
24 , 000
9 , 600
None
PRE-INCIDENT VALUE: Optional
Property
$
Contents
$
X
Hazardous Materials Release
161 , 000
, 80 , 400
,
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.)
X
Special
Study ID#
LAST UNIT CLEARED, required except for wildland fires
Resources
G1
Primary Action Taken (1)
51
01 2005
CONTROLLED optional, except for wildland fires
Their
State
Their Incident Number
F
05
Arrival
I
Mixed Use
Property
10
20
33
40
51
53
58
59
60
63
65
00
X
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
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
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
A-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
K1
Local Option
Business Name (if applicable)
Check this box if same
address as incident
Location (Section B).
Then skip the three
duplicate address
lines.
X
Area Code
Christy
A
First Name
Mr., Ms., Mrs.
Phone Number
Gordon
MI
Last Name
Suffix
East Cary
5
Number
Prefix
ST
Street or Highway
Street Type
Suffix
Brunswick
Post Office Box
VA
Apt./Suite/Room
City
23351
State
ZIP Code
More people involved? Check this box and attach Supplemental Forms (NFIRS–1S) as necessary.
as person involved?
X Same
Then check this box and skip
Owner
K2
Local Option
Check this box if same
address as incident
Location (Section B).
Then skip the three
duplicate address
lines.
the rest of this block.
Mr., Ms., Mrs.
Business Name (if applicable)
First Name
Number
MI
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:
L
Local Option
Mrs. Christy A. Gordon was warming her lunch on the stove
when the grease from the pan began to burn.
Fire Module Required?
Check the box that applies and then complete the Fire Module
based on Incident Type, as follows:
Complete Fire & Structure Modules
Complete Fire Module &
Section I, Structure Module
Basic Module Only
Confined 113–118
Complete Fire Module
Mobile property 120–123
Complete Fire Module
Vehicle 130–138
Complete Fire or Wildland Module
Vegetation 140–143
Outside rubbish fire 150–155 Basic Module Only
Complete Fire or Wildland Module
Special outside fire 160
Special outside fire 161–163 Complete Fire Module
Complete Fire or Wildland Module
Crop fire 170–173
Buildings 111
Special structure 112
ITEMS WITH A
MUST ALWAYS BE COMPLETED!
More remarks? Check this box and attach Supplemental Forms (NFIRS–1S) as necessary.
M
Authorization
Check box if
same as
Officer in
charge.
105
Officer in charge ID
Tonya Gordon
Signature
224
Member making report ID
Captain
Position or rank
Adam Wallner
Signature
05
Assignment
Month
Assignment
Month
FF1
Position or rank
A-23
05
01
Day
01
Day
2005
Year
2005
Year
NFIRS 5.0 Self-Study Program
A
92188
FDID
B
MM
DD
05
VA
YYYY
01
2005
Incident Date
State
Station
Property Details
C
1
B1
0 0 0 5 4 3 3
002
Not Residential
Incident Number
On-Site Materials
or Products
None
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
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
Estimated number of residential living units in
building of origin whether or not all units
became involved
B2
Buildings not involved
Number of buildings involved
B3
None
,
Less than one acre
Acres burned (outside fires)
On-site material (3)
D
Ignition
E1
D1 2 4 Cooking area, kitchen
1
2
3
4
5
U
Area of fire origin
8 1 Heat from direct flame
D2 Heat
source
D4
confined to object of origin.
Skip to
Section G
Check box if this is an exposure report.
E3
X
Factors Contributing to Ignition
Estimated age of
person involved
Required only if item first
ignited code is 00 or <70
None
F2
1
6 4 6 Range with or without oven
Equipment Involved
Serial #
Whirlpool
RF330PXVN
F925888840
Year
2000
Brand
Model
H1
Mobile Property Involved
1
Not involved in ignition, but burned
2
Involved in ignition, but did not burn
3
Involved in ignition and burned
Equipment Power Source
Equipment Portability
Fire Suppression Factors
Female
X None
Enter up to three codes.
2
X
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.
H2
Fire suppression factor (1)
Portable
1
None
2
Male
Equipment Power Source
F3
X
G
2 1 Natural Gas or other
If equipment was not involved, skip to
Section G
Age was a factor
7
Factor contributing to ignition (1)
Equipment Involved in Ignition
None
1 X Asleep
2 Possibly impaired by
alcohol or drugs
3 Unattended person
4 Possibly mentally disabled
5 Physically disabled
None
6 Multiple persons involved
Factor contributing to ignition (2)
F1
Human Factors
Contributing to Ignition
Intentional
Unintentional
Failure of equipment or heat source
Act of nature
Cause under investigation
Cause undetermined after investigation
5 3 Equipment unattended
2 7 Cooking oil, transorme
Type of material first ignited
Cause of Ignition
Check all applicable boxes
D3 7 6 Cooking materials, incl E2
Item first ignited
Check box if fire spread was
1
Fire
Change
Exposure
X
NFIRS–2
Delete
0
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
A-24
NFIRS 5.0 Self-Study Program
Structure Type
I1
If fire was in an enclosed building or a
portable/mobile structure, complete the
rest of this form.
X Enclosed building
1
2
3
4
5
6
7
8
0
Portable/mobile structure
Open structure
Air-supported structure
Tent
Open platform (e.g., piers)
Underground structure (work areas)
Connective structure (e.g., fences)
Other type of structure
Fire Origin
J1
1
I2
Building Status
1
2
3
4
5
6
7
0
U
Under construction
Occupied & operating
Idle, not routinely used
Under major renovation
Vacant and secured
Vacant and unsecured
Being demolished
Other
Undetermined
J3
Below grade
Story of
fire origin
Fire Spread
J2
2
3
4
5
If fire spread was confined to object of origin,
do not check a box (Ref. Block D3, Fire Module).
X Confined to room of origin
Confined to floor of origin
Confined to building of origin
Beyond building of origin
Presence of Detectors
L1
1
U
X
Skip to
Section M
Present
Undetermined
Detector Type
L2
1
2
3
4
5
0
U
None Present
X
M1
Smoke
Heat
Combination smoke and heat
Sprinkler, water flow detection
More than one type present
Other
Undetermined
1
2
3
4
5
6
7
0
U
Number of stories w/significant damage
(25 to 49% flame damage)
0
Number of stories w/heavy damage
(50 to 74% flame damage)
0
Number of stories w/extreme damage
(75 to 100% flame damage)
Detector Power Supply
L4
Detector Operation
1
Fire too small to activate
X
Operated
Complete
Block L5
3
Failed to operate
Complete
Block L6
U
Undetermined
2
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
M3
,
K
Check if no flame spread OR if
same as Material First Ignited (Block D4,
Fire Module) OR if unable to determine.
K1
Skip to
Section L
Item contributing most to flame spread
K2
Type of material contributing
most to flame spread
1
2
Detector Effectiveness
X
3
4
U
L6
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
Number of Sprinkler
Heads Operating
Required if system operated
Required only if item
contributing code is 00 or <70.
Required if detector operated.
Operated/effective (go to M4)
Operated/not effective (go to M4)
Fire too small to activate
Failed to operate (go to M5)
Other
Undetermined
M4
Width in feet
Type of Material Contributing Most
to Flame Spread
M5
Required if fire was within designed range
1
2
3
4
0
U
,
BY
Length in feet
L5
Battery only
Hardwire only
Plug-in
Hardwire with battery
Plug-in with battery
Mechanical
Multiple detectors & power
supplies
Other
Undetermined
0
U
1 , 0 0 0
,
Total square feet
0
Total number of stories
below grade
0
X
NFIRS–3
Structure
Fire
OR
Number of stories w/minor damage
(1 to 24% flame damage)
Type of Automatic Extinguishing System
Required if fire was within designed range of AES
2
Total number of stories at or
above grade
1
1
2
3
4
5
6
7
Main Floor Size
I4
Count the roof as part of the
highest story.
Count the roof as part of the highest story.
Presence of Automatic Extinguishing System
N X None Present
Present
1
Complete rest of
Section M
2
Partial System Present
U
Undetermined
M2
Building
Height
Number of Stories Damaged by Flame
L3
(In area of the fire)
N
X
I3
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
A-25
Revision 01/01/06
NFIRS 5.0 Self-Study Program
VA
A 92188
FDID
State
MM
DD
05
YYYY
01
2005
Incident Date
Christy
Gordon
MI
Age or Date of Birth
D
66
Months (for infants)
Age
E1
1
2
3
4
5
Date of Birth
1
Day
Year
Black, African American
Am. Indian, Alaska Native
Asian
Native Hawaiian, Other
Pacific Islander
E2
1
0
X
1
2
3
4
5
6
7
8
0
U
Escaping
Rescue attempt
Fire control
Return to fire before control
Return to fire after control
Sleeping
Unable to act
Irrational act
Other
Undetermined
X
M1
X
1
2
3
0
05
Month
Time of Injury
01
Day
2005
Year
1 2 5 0
Hour
K
None
Severity
1
2
3
4
5
U
X
Minor
Moderate
Severe
Life threatening
Death
Undetermined
Minute
Factors Contributing
to Injury
None
Enter up to three contributing factors
23
Check all applicable boxes
X
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
In area of origin and not involved
M3
Vision blocked or impaired by smoke
Contributing factor (1)
63
Improper use of cooking equipment
Contributing factor (2)
Contributing factor (3)
Story at Start of Incident
Complete ONLY if injury occurred INSIDE
Not in area of origin and not involved
X 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
2
Story at start of incident
M4
M2
X
Midnight is 0000.
Date and Time of Injury
Location at Time of Incident
1
2
3
4
0
U
Casualty Number
H
Civilian
EMS, not fire department
Police
Other
Human Factors
Contributing to Injury
J
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
Activity When Injured
Affiliation
Date of Injury
Hispanic or Latino
Non Hispanic or Latino
X Exposed to fire products including flame
L
G
Ethnicity
Cause of Injury
2
3
4
5
6
7
8
9
0
U
1
F
Other, multiracial
Undetermined
Casualty
Number
C
Suffix
Race
0
U
Change
X Female
Last Name
X White
OR
Month
2
NFIRS–4
Civilian Fire
Casualty
Delete
Exposure
Gender
1
Male
First Name
0
Incident Number
Station
Injured Person
B
I
0 0 0 5 4 3 3
002
Story Where Injury Occurred
Story where injury occurred, if
different from M3
M5
Below grade
2
Below grade
Specific Location at Time of Injury
Complete ONLY if casualty NOT in area of origin
Skip to
Block M5
21
Bedroom - < 5 persons; incl
Specific location at time of injury
Primary Apparent Symptom
N
01
11
12
21
33
96
98
X
Smoke only, asphyxiation
Burns and smoke inhalation
Burns only
Cut, laceration
Strain or sprain
Shock
Pain only
Look up a code only if the symptom is NOT found above
Primary apparent symptom
O
Primary Area of Body Injured
P
Disposition
X Transported to emergency care facility
1
2
3
4
5
6
7
8
9
X
Head
Neck and shoulder
Thorax
Abdomen
Spine
Upper extremities
Lower extremities
Internal
Multiple body parts
Remarks
Local option
NFIRS–4
A-26
Revision 01/01/04
NFIRS 5.0 Self-Study Program
A
MM
VA
92188
FDID
DD
05
2005
Station
317
M
First Name
1
2
G1
1
2
3
4
5
6
7
8
0
X
H1
Date of Injury
05
Usual Assignment
Suppression
EMS
Prevention
Training
Maintenance
Communications
Administration
Fire investigation
Other
Day
Year
X
1
2
4
Rested
Fatigued
Ill or injured
X
I1
Strain or sprain
Ankle
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
X
J2
1
2
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
0
U
G4
Taken To
1
4
5
6
7
0
Other
Undetermined
Minute
X
Activity at Time of Injury
G5
91
Incident investigation, during
Activity at time of injury
Cause of Firefighter Injury
3
Not transported
Hospital
Doctor’s office
Morgue/funeral home
Residence
Station or quarters
Other
I3
Slip/trip
Object Involved
in Injury
None
I2
Factor Contributing to Injury
53
None
Loose material on surface
42
1
Dirt, stones, or debris
Object involved in injury
Contributing factor
Primary injured body part
J1
Hour
Number of prior responses
during past 24 hours
Cause of injury
None
Primary Part of Body Injured
74
Year
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
H2
Day
0
1 4 1 5
2 0 0 5
Severity
1
2
3
4
5
6
7
Primary Apparent Symptom
33
Month
0 1
Responses
F
Time of Injury
Physical Condition Just Prior to Injury
G2
G3
1
Midnight is 0000.
Date and Time of Injury
E
Month
Casualty Number
Suffix
OR
In years
C
Fire Service
Casualty
Casualty Number
Date of Birth
36
Change
Career
Volunteer
1
2
Female
Last Name
MI
Age
Exposure
X Male
NFIRS–5
Delete
Mills
Age or Date of Birth
D
0
Incident Number
Identification Number
Juan
0 0 0 5 4 3 3
002
Incident Date
State
Injured Person
B
YYYY
01
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
X
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
A-27
J4
Vehicle Type
1
2
3
4
Suppression vehicle
EMS vehicle
Other FD vehicle
Non-FD vehicle
Complete ONLY if
Specific Location code
is >60
Remarks
If protective equipment failed and
was a factor in this injury, please
complete the other side of this
form.
NFIRS–5 Revision 01/01/05
NFIRS 5.0 Self-Study Program
K1
K2
Did protective equipment fail and contribute to the injury?
Yes
Y
Please complete the remainder of this form ONLY if you answer YES.
No
NX
Protective Equipment Item
K3
Head or Face Protection
Coat, Shirt, or Trousers
11
12
13
14
15
16
17
10
21
22
23
24
25
26
27
28
20
NFIRS–5
Equipment
Sequence
Number
Fire Service
Casualty
Protective Equipment Problem
Check one box to indicate the main problem that occurred.
11
Burned
12
Melted
21
Fractured, cracked or broken
22
Punctured
23
Scratched
24
Knocked off
25
Cut or ripped
31
Trapped steam or hazardous gas
32
Insufficient insulation
33
Object fell in or onto equipment item
41
Failed under impact
42
Face piece or hose detached
43
Exhalation valve inoperative or damaged
44
Harness detached or separated
45
Regulator failed to operate
46
Regulator damaged by contact
47
Problem with admissions valve
48
Alarm failed to operate
49
Alarm damaged by contact
51
Supply cylinder or valve failed to operate
52
Supply cylinder/valve damaged by contact
Special Equipment
53
Supply cylinder—insufficient air/oxygen
61
62
63
64
65
66
67
68
69
71
72
73
74
75
76
77
78
79
70
00
94
Did not fit properly
95
Not properly serviced or stored prior to use
96
Not used for designed purpose
97
Not used as recommended by manufacturer
00
Other equipment problem
UU
Undetermined
Helmet
Full face protector
Partial face protector
Goggles/eye protection
Hood
Ear protector
Neck protector
Other
Protective coat
Protective trousers
Uniform shirt
Uniform T-shirt
Uniform trousers
Uniform coat or jacket
Coveralls
Apron or gown
Other
Boots or Shoes
31
32
33
34
35
36
37
38
30
Knee length boots with steel baseplate and steel toes
Knee length boots with steel toes only
3/4 length boots with steel baseplate and steel toes
3/4 length boots with steel toes only
Boots without steel baseplate and steel toes
Safety shoes with steel baseplate and steel toes
Safety shoes with steel toes only
Non-safety shoes
Other
Respiratory Protection
41
42
43
44
45
46
40
SCBA (demand) open circuit
SCBA (positive pressure) open circuit
SCBA closed circuit
Not self-contained
Cartridge respirator
Dust or particle mask
Other
Hand Protection
51
52
53
54
55
50
Firefighter gloves with wristlets
Firefighter gloves without wristlets
Work gloves
HazMat gloves
Medical gloves
Other
Proximity suit for entry
Proximity suit for non-entry
Totally encapsulated, reusable chemical suit
Totally encapsulated, disposable chemical suit
Partially encapsulated, reusable chemical suit
Partially encapsulated, disposable chemical suit
Flash protection suit
Flight or jump suit
Brush suit
Exposure suit
Self-contained underwater breathing apparatus (SCUBA)
Life preserver
Life belt or ladder belt
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
A-28
K4
Equipment Manufacturer, Model and Serial
Number
Manufacturer
Model
Serial Number
NFIRS–5
Revision 05/01/03
NFIRS 5.0 Self-Study Program Appendix A
Emergency Medical
Services (EMS) Module:
NFIRS-6
Scenario 6-2 Answers
A-29
NFIRS 5.0 Self-Study Program
A 92188
FDID
B
DD
05
YYYY
03
2005
Station
Delete
000
Incident Number
Prefix
Exposure
Basic
No Activity
0501-10
Census Tract
ST
Street or Highway
Street Type
Brunswick
Apt./Suite/Room
NFIRS–1
Change
I-95
MM 73
Number/Milepost
VA
City
23351
State
Near Exit 2B
Suffix
-
ZIP Code
Cross Street, Directions or National Grid, as applicable
Incident Type
X
Aid Given or Received
Dates and Times
E1
Vehicle accident
None
Midnight is 0000
Month
Check boxes if
dates are the
same as Alarm
Date.
Incident Type
D
0 0 0 5 4 5 5
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
322
001
Incident Date
State
Location Type
X
C
MM
VA
Day
Year
ALARM always required
05
Alarm
03
Hour
2005
E2
Min
Shifts and Alarms
Local Option
C
2358
Shift or
Platoon
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
Controlled
Last Unit
Cleared
Actions Taken
32
Additional Action Taken (2)
EMS
Other
Additional Action Taken (3)
Civilian Fire Cas.–4
Fire Service Cas.–5
EMS–6
HazMat–7
Wildland Fire–8
Apparatus–9
Personnel–10
Arson–11
05
05
Personnel
0
2
0
0
8
0
Check box if resource counts include aid
received resources.
Casualties
X
None
Deaths Injuries
Fire
Service
Civilian
H2
1
2
U
Special Studies
Local Option
Detector
Required for confined fires.
Detector alerted occupants
Detector did not alert them
Unknown
H3
1
2
3
4
5
6
7
8
0
0025
04 2005
G2
Apparatus
Suppression
H1
E3
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.
Primary Action Taken (1)
Fire–2
Structure Fire–3
0004
04 2005
Resources
G1
Provide basic life support
Completed Modules
04 2005
CONTROLLED optional, except for wildland fires
Their
State
Their Incident Number
F
05
Arrival
0035
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
Property
$
,
,
Contents
$
,
,
X
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.)
I
Mixed Use
Property
10
20
33
40
51
53
58
59
60
63
65
00
X
Not mixed
Assembly use
Education use
Medical use
Residential use
Row of stores
Enclosed mall
Business & residential
Office use
Industrial use
Military use
Farm use
Other mixed use
Property Use
None
Structures
Church, place of worship
131
Restaurant or cafeteria
161
Bar/tavern or nightclub
162
Elementary school, kindergarten
213
High school, junior high
215
College, adult education
241
Nursing home
311
Hospital
331
341
342
361
419
429
439
449
459
464
519
Clinic, clinic-type infirmary
Doctor/dentist office
Prison or jail, not juvenile
1- or 2-family dwelling
Multifamily dwelling
Rooming/boarding house
Commercial hotel or motel
Residential, board and care
Dormitory/barracks
Food and beverage sales
539
571
579
599
615
629
700
819
882
891
Household goods, sales, repairs
Gas or service station
Motor vehicle/boat sales/repairs
Business office
Electric-generating plant
Laboratory/science laboratory
Manufacturing plant
Livestock/poultry storage (barn)
Non-residential parking garage
Warehouse
Outside
Playground or park
124
Crops or orchard
655
Forest (timberland)
669
Outdoor storage area
807
Dump or sanitary landfill
919
Open land or field
931
936
938
946
951
960
961
962
Vacant lot
Graded/cared for plot of land
Lake, river, stream
Railroad right-of-way
Other street
Highway/divided highway
Residential street/driveway
981
984
Construction site
Industrial plant yard
J
X
A-30
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
K1
555
Local Option
Business Name (if applicable)
Check this box if same
address as incident
Location (Section B).
Then skip the three
duplicate address
lines.
Area Code
Robert
X
L
First Name
Mr., Ms., Mrs.
432
Anderson
MI
Last Name
Suffix
Second
1630
Number
Prefix
0 9 8 7
Phone Number
Ave
Street or Highway
Street Type
Suffix
Jarrett
Post Office Box
NC
Apt./Suite/Room
City
24501
State
ZIP Code
More people involved? Check this box and attach Supplemental Forms (NFIRS–1S) as necessary.
as person involved?
X Same
Then check this box and skip
Owner
K2
Local Option
Check this box if same
address as incident
Location (Section B).
Then skip the three
duplicate address
lines.
the rest of this block.
Mr., Ms., Mrs.
Business Name (if applicable)
First Name
Number
MI
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:
L
Local Option
He said that his front seat caught on fire from a cigarette.
He was drowsy from a prescription drug that he took.
Fire Module Required?
Check the box that applies and then complete the Fire Module
based on Incident Type, as follows:
Complete Fire & Structure Modules
Complete Fire Module &
Section I, Structure Module
Basic Module Only
Confined 113–118
Complete Fire Module
Mobile property 120–123
Complete Fire Module
Vehicle 130–138
Complete Fire or Wildland Module
Vegetation 140–143
Outside rubbish fire 150–155 Basic Module Only
Complete Fire or Wildland Module
Special outside fire 160
Special outside fire 161–163 Complete Fire Module
Complete Fire or Wildland Module
Crop fire 170–173
Buildings 111
Special structure 112
ITEMS WITH A
MUST ALWAYS BE COMPLETED!
More remarks? Check this box and attach Supplemental Forms (NFIRS–1S) as necessary.
M
Authorization
Check box if
same as
Officer in
charge.
100
Officer in charge ID
Ernest Greene
Signature
230
Member making report ID
Captain
Position or rank
Steve LaCivita
Signature
05
Assignment
Month
Assignment
Month
FF1
Position or rank
A-31
05
04
Day
04
Day
2005
Year
2005
Year
NFIRS 5.0 Self-Study Program
92188
A
FDID
DD
05
YYYY
03
2005
Patient Number
1
18
19
20
21
22
23
24
25
Abdominal pain
Airway obstruction
Allergic reaction
Altered LOC
Behavioral/psych
Burns
Cardiac arrest
Cardiac dysrhythmia
Age or Date of Birth
E1
49
F1
Months (for infants)
Age
OR
Month
Day
Gender
E2
1
X
Male
F2
2
X
Female
1
34
35
36
37
38
00
Hypovolemia
Inhalation injury
Obvious death
OD/poisoning
Pregnancy/OB
Respiratory arrest
Respiratory distress
Seizure
Hour/Min
Human Factors
Contributing to Injury
Sexual assault
Sting/bite
Stroke/CVA
Syncope
Trauma
Other
None
G2
X
X
Asleep
Unconscious
Possibly impaired by alcohol
Possibly impaired by drug
Possibly mentally disabled
Physically disabled
Physically restrained
Unattended person
1
2
3
Injury Type
16
X
None
Accidental
Self-inflicted
Inflicted, not self
H3
List one injury type for each body site listed under H1
Head
Other
Factors
If an illness, not an
injury, skip G2 and
go to H3
Check all applicable boxes
1
2
3
4
5
6
7
8
Hispanic or Latino
Non Hispanic or Latino
H2
26
27
28
29
30
31
32
33
G1
Ethnicity
List up to five body sites
Year
2005 0006
0025
None/no patient or refused treatment
Chest pain
Diabetic symptom
Do not resuscitate
Electrocution
General illness
Hemorrhaging/bleeding
Hyperthermia
Hypothermia
Body Site of Injury
H1
Day
04
Time of Patient Transfer
White
Black, African American
Am. Indian, Alaska Native
Asian
Native Hawaiian, Other
Pacific Islander
Other, multiracial
Undetermined
1
2
EMS
Change
05
Check one box only
X
0
U
Year
Time Arrived at Patient
NFIRS–6
Delete
Exposure
Month
Date/Time
Race
1
2
3
4
5
Incident Number
Check if same date
as Alarm date
Provider Impression/Assessment
10
11
12
13
14
15
16
17
C
0
0 0 0 5 4 5 5
Station
Use a separate form for each patient
D
001
Incident Date
State
Number of Patients
B
MM
VA
Laceration
Cause of
Illness/Injury
2 9
Cause of illness/injury
Motor vehicle
Procedures Used
I
01
02
03
04
05
06
07
08
09
10
11
12
13
L1
1
2
3
4
0
N
X
Check all applicable boxes
Airway insertion
Anti-shock trousers
Assist ventilation
Bleeding control
Burn care
Cardiac pacing
Cardioversion (defib) manual
Chest/abdominal thrust
CPR
Cricothyroidotomy
Defibrillation by AED
EKG monitoring
Extrication
Initial Level of
Provider
First Responder
X EMT-B (Basic)
EMT-I (Intermediate)
EMT-P (Paramedic)
Other provider
No Training
L2
1
2
3
4
0
14
15
16
17
18
19
20
21
22
23
24
00
No treatment
Intubation (EGTA)
Intubation (ET)
IO/IV therapy
Medications therapy
1
Oxygen therapy
2
OB care/delivery
3
Prearrival instructions 4
Restrain patient
5
Spinal immobilization 6
Splinted extremities
0
Suction/aspirate
U
Other
Highest Level of Care
Provided On Scene
X
J
First Responder
EMT-B (Basic)
EMT-I (Intermediate)
EMT-P (Paramedic)
Other provider
None
M
1
2
3
Safety
Equipment
Used or deployed by patient.
Check all applicable boxes.
Safety/seat belts
Child safety seat
Airbag
Helmet
Protective clothing
Flotation device
Other
Undetermined
Improved
Remained same
Worsened
Check if:
1
2
A-32
X
Check all applicable boxes
Pre-arrival arrest?
1
If pre-arrival arrest, was it:
Patient Status
X
Cardiac Arrest
X None K
Pulse on transfer
No pulse on transfer
2
1
Witnessed?
2
Bystander CPR?
Post-arrival arrest?
Initial Arrest Rhythm
1
0
U
N
1
2
3
4
0
V-Fib/V-Tach
Other
Undetermined
EMS
Disposition
X Not transported
FD transport to ECF
Non-FD transport
Non-FD trans/FD attend
Non-emergency transfer
Other
NFIRS–6 Revision 01/01/04
NFIRS 5.0 Self-Study Program Appendix A
Hazardous Materials
Module: NFIRS-7
Scenario 7-2 Answers
A-33
NFIRS 5.0 Self-Study Program
A 92188
FDID
B
DD
05
YYYY
03
2005
Station
Delete
000
Incident Number
Prefix
Exposure
Basic
No Activity
0501-10
Census Tract
Hwy
Street or Highway
Street Type
Brunswick
Apt./Suite/Room
NFIRS–1
Change
I-95
MM 73
Number/Milepost
VA
City
23351
State
Near Exit 2B
Suffix
-
ZIP Code
Cross Street, Directions or National Grid, as applicable
Incident Type
X
Aid Given or Received
Dates and Times
E1
Chemical Spill or
None
Midnight is 0000
Month
Check boxes if
dates are the
same as Alarm
Date.
Incident Type
D
0 0 0 5 4 5 5
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
422
001
Incident Date
State
Location Type
X
C
MM
VA
Day
Year
ALARM always required
05
Alarm
03
Hour
2005
E2
Min
Shifts and Alarms
Local Option
C
2358
Shift or
Platoon
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
EMS
Other
Additional Action Taken (3)
Civilian Fire Cas.–4
Fire Service Cas.–5
EMS–6
HazMat–7
Wildland Fire–8
Apparatus–9
Personnel–10
Arson–11
04 2005
G2
Apparatus
Suppression
Additional Action Taken (2)
Fire–2
Structure Fire–3
05
Check this box and skip this block if an
Apparatus or Personnel Module is used.
Identify, analyze
hazardous materials
Completed Modules
Personnel
2
0
1
8
0
5
Check box if resource counts include aid
received resources.
H1
Casualties
X
None
Deaths Injuries
Fire
Service
Civilian
H2
1
2
U
E3
Special Studies
Local Option
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 ID#
LAST UNIT CLEARED, required except for wildland fires
Resources
G1
Hazardous materials leak
control and containment
Primary Action Taken (1)
41
0004
Controlled
Actions Taken
44
04 2005
CONTROLLED optional, except for wildland fires
Their
State
Their Incident Number
F
05
Arrival
0105
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
Property
$
,
,
Contents
$
,
,
X
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.)
I
Mixed Use
Property
10
20
33
40
51
53
58
59
60
63
65
00
X
Not mixed
Assembly use
Education use
Medical use
Residential use
Row of stores
Enclosed mall
Business & residential
Office use
Industrial use
Military use
Farm use
Other mixed use
Property Use
None
Structures
Church, place of worship
131
Restaurant or cafeteria
161
Bar/tavern or nightclub
162
Elementary school, kindergarten
213
High school, junior high
215
College, adult education
241
Nursing home
311
Hospital
331
341
342
361
419
429
439
449
459
464
519
Clinic, clinic-type infirmary
Doctor/dentist office
Prison or jail, not juvenile
1- or 2-family dwelling
Multifamily dwelling
Rooming/boarding house
Commercial hotel or motel
Residential, board and care
Dormitory/barracks
Food and beverage sales
539
571
579
599
615
629
700
819
882
891
Household goods, sales, repairs
Gas or service station
Motor vehicle/boat sales/repairs
Business office
Electric-generating plant
Laboratory/science laboratory
Manufacturing plant
Livestock/poultry storage (barn)
Non-residential parking garage
Warehouse
Outside
Playground or park
124
Crops or orchard
655
Forest (timberland)
669
Outdoor storage area
807
Dump or sanitary landfill
919
Open land or field
931
936
938
946
951
960
961
962
Vacant lot
Graded/cared for plot of land
Lake, river, stream
Railroad right-of-way
Other street
Highway/divided highway
Residential street/driveway
981
984
Construction site
Industrial plant yard
J
X
A-34
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
K1
Local Option
Check this box if same
address as incident
Location (Section B).
Then skip the three
duplicate address
lines.
Business Name (if applicable)
Mr., Ms., Mrs.
First Name
Number
Prefix
Post Office Box
State
Area Code
MI
Phone Number
Last Name
Suffix
Street or Highway
Street Type
Apt./Suite/Room
Suffix
City
ZIP Code
More people involved? Check this box and attach Supplemental Forms (NFIRS–1S) as necessary.
Owner
K2
Local Option
Check this box if same
address as incident
Location (Section B).
Then skip the three
duplicate address
lines.
Same as person involved?
Then check this box and skip
the rest of this block.
Mr., Ms., Mrs.
Business Name (if applicable)
First Name
Number
MI
Prefix
Post Office Box
State
Area Code
Phone Number
Last Name
Suffix
Street or Highway
Street Type
Apt./Suite/Room
Suffix
City
ZIP Code
Remarks:
L
Local Option
Fire Module Required?
Check the box that applies and then complete the Fire Module
based on Incident Type, as follows:
Complete Fire & Structure Modules
Complete Fire Module &
Section I, Structure Module
Basic Module Only
Confined 113–118
Complete Fire Module
Mobile property 120–123
Complete Fire Module
Vehicle 130–138
Complete Fire or Wildland Module
Vegetation 140–143
Outside rubbish fire 150–155 Basic Module Only
Complete Fire or Wildland Module
Special outside fire 160
Special outside fire 161–163 Complete Fire Module
Complete Fire or Wildland Module
Crop fire 170–173
Buildings 111
Special structure 112
ITEMS WITH A
MUST ALWAYS BE COMPLETED!
More remarks? Check this box and attach Supplemental Forms (NFIRS–1S) as necessary.
M
Authorization
Check box if
same as
Officer in
charge.
Officer in charge ID
Signature
Position or rank
Assignment
Month
Day
Year
Member making report ID
Signature
Position or rank
Assignment
Month
Day
Year
A-35
NFIRS 5.0 Self-Study Program
A 92188
FDID
None
7782-44-7
Estimated Container Capacity
C2
,
Complete the remainder
of this form only for the
first hazardous material
involved in this incident.
C3
11
12
13
14
15
16
Units: Capacity
VOLUME
Ounces
Gallons
Barrels: 42 gal.
Liters
Cubic feet
Cubic meters
X
Population Density
F2
X
1
2
3
Urban
Suburban
Rural
Check all applicable boxes
Below grade
Inside/on structure
Story of release
X
Outside of structure
G1
1
2
3
X
11
12
13
14
MICRO UNITS 15
Enter Code 16
G2
G4
Blocks
J
Cause of Release
1
2
3
4
5
U
Intentional
Unintentional release
Container/containment failure
Act of nature
Cause under investigation
Cause undetermined after
investigation
K
None
M
Equipment Involved
in Release
Brand
Enter up to three actions taken
11
Identify, analyze
hazardous materials
Remove hazard or
hazardous materials
Additional action taken (2)
22
Isolate area &
Estimated Number of
Buildings Evacuated
None
L
If fire or explosion is involved with a
release, which occurred first?
I
1
2
Ignition
Release
U
Undetermined
X
Factors Affecting Mitigation
None
Enter up to three factors or impediments that affected the
mitigation of the incident
Factor contributing to release (1)
Factor or impediment (1)
Factor contributing to release (2)
Factor or impediment (2)
Factor contributing to release (3)
Factor or impediment (3)
N
Mobile Property Involved in
None
Release
23
Equipment involved in release
HazMat Actions Taken
Collision, overturn,
knockdown
71
None
1-Air
Released into
Additional action taken (3)
Enter up to three contributing factors
X
Released Into
E2
Enter Code
15
0
Factors Contributing to Release
X
Solid
Liquid
Gas
Undetermined
Primary action taken (1)
Estimated Number of
People Evacuated
0
WEIGHT
Ounces
Pounds
Grams
Kilograms
MICRO UNITS
21
22
23
24
H
0
Enter
measurement
Square miles
,
Enter measurement
X
,
,
15
1
2
3
U
Check one box
VOLUME
Ounces
Gallons
Barrels: 42 gal.
Liters
Cubic feet
Cubic meters
Square feet
Blocks
,
X
HazMat
State
E1 Physical
When Released
90
,
Units: Released
Area Evacuated
Square feet
Square miles
Haz No.
Oxygen (compressed gas)
,
WEIGHT
Ounces
Pounds
Grams
Kilograms
G3
Area Affected
Change
Estimated Amount Released
D2
NFIRS–7
Delete
Amount released: by volume or weight
1
2
3
Released From
1
Exposure
Chemical
Name
D1
122
Check one box
21
22
23
24
0
Incident Number
CAS Registration Number
,
More hazardous
materials? Use
additional sheets.
1
0 0 0 5 4 5 5
Capacity: by volume or weight
Container Type
F1
001
Station
DOT Hazard
Classification
12
2
2005
2 2
1 0 7 2
Container
Type
YYYY
03
Incident Date
UN Number
C1
DD
05
State
HazMat ID
B
MM
VA
Trailer - semi, designed f
Mobile property type
Mobile property make
Model
Model
Year
O
1
2
3
4
5
6
7
8
Serial #
License plate number
State
Year
P
HazMat Disposition
X Completed by fire service only
Completed w/fire service present
Released to local agency
Released to county agency
Released to state agency
Released to federal agency
Released to private agency
Released to property owner or
manager
HazMat Civilian Casualties
Deaths
0
DOT number/ ICC number
A-36
Injuries
0
NFIRS–7
Revision 01/01/06
NFIRS 5.0 Self-Study Program Appendix A
Wildland Fire Module:
NFIRS-8
Scenario 8-2 Answers
A-37
NFIRS 5.0 Self-Study Program
A 92188
FDID
B
DD
05
YYYY
03
2005
Station
Incident Number
NFIRS–1
Change
Exposure
Basic
No Activity
0501-10
Census Tract
I-95
MM 73
Number/Milepost
Prefix
Street or Highway
Street Type
Brunswick
Apt./Suite/Room
VA
City
23351
State
Near Exit 2B
Suffix
-
ZIP Code
Cross Street, Directions or National Grid, as applicable
Incident Type
Dates and Times
E1
Grass fire
X
Aid Given or Received
None
Midnight is 0000
Month
Check boxes if
dates are the
same as Alarm
Date.
Incident Type
D
Delete
0
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
143
0 0 0 5 4 5 5
Incident Date
State
Location Type
X
C
MM
VA
Day
Year
ALARM always required
05
Alarm
03
Hour
2005
E2
Min
Shifts and Alarms
Local Option
C
2358
Shift or
Platoon
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
Controlled
Last Unit
Cleared
Actions Taken
11
Additional Action Taken (2)
EMS
Other
Additional Action Taken (3)
Civilian Fire Cas.–4
Fire Service Cas.–5
EMS–6
HazMat–7
Wildland Fire–8
Apparatus–9
Personnel–10
Arson–11
05
Casualties
X
None
Deaths Injuries
Fire
Service
Civilian
H2
1
2
U
Special Studies
Local Option
Detector
Required for confined fires.
Detector alerted occupants
Detector did not alert them
Unknown
341
342
361
419
429
439
449
459
464
519
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
H3
1
2
3
4
5
6
7
8
0
0040
04 2005
G2
Personnel
1
0
0
4
0
0
Check box if resource counts include aid
received resources.
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
J
05
Apparatus
Suppression
H1
E3
0105
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
Property
$
,
,
Contents
$
,
,
X
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.)
X
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.
Primary Action Taken (1)
Fire–2
Structure Fire–3
0004
04 2005
Resources
G1
Extinguish
Completed Modules
04 2005
CONTROLLED optional, except for wildland fires
Their
State
Their Incident Number
F
05
Arrival
I
Mixed Use
Property
10
20
33
40
51
53
58
59
60
63
65
00
X
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
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
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
A-38
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
K1
555
Local Option
Check this box if same
address as incident
Location (Section B).
Then skip the three
duplicate address
lines.
Business Name (if applicable)
Area Code
L
Robert
X
First Name
Mr., Ms., Mrs.
432
Anderson
MI
Last Name
Suffix
Second
1630
Number
Prefix
0 9 8 7
Phone Number
Ave
Street or Highway
Street Type
Suffix
Jarrett
Post Office Box
NC
Apt./Suite/Room
City
24501
State
ZIP Code
More people involved? Check this box and attach Supplemental Forms (NFIRS–1S) as necessary.
Owner
K2
Local Option
Check this box if same
address as incident
Location (Section B).
Then skip the three
duplicate address
lines.
Same as person involved?
Then check this box and skip
the rest of this block.
Mr., Ms., Mrs.
Business Name (if applicable)
First Name
Number
MI
Prefix
Post Office Box
State
Area Code
Phone Number
Last Name
Suffix
Street or Highway
Street Type
Apt./Suite/Room
Suffix
City
ZIP Code
Remarks:
L
Local Option
Fire Module Required?
Check the box that applies and then complete the Fire Module
based on Incident Type, as follows:
Complete Fire & Structure Modules
Complete Fire Module &
Section I, Structure Module
Basic Module Only
Confined 113–118
Complete Fire Module
Mobile property 120–123
Complete Fire Module
Vehicle 130–138
Complete Fire or Wildland Module
Vegetation 140–143
Outside rubbish fire 150–155 Basic Module Only
Complete Fire or Wildland Module
Special outside fire 160
Special outside fire 161–163 Complete Fire Module
Complete Fire or Wildland Module
Crop fire 170–173
Buildings 111
Special structure 112
ITEMS WITH A
MUST ALWAYS BE COMPLETED!
More remarks? Check this box and attach Supplemental Forms (NFIRS–1S) as necessary.
M
Authorization
Check box if
same as
Officer in
charge.
Ernest Greene
Officer in charge ID
Signature
123
Member making report ID
Captain
Position or rank
Michael Harris
Signature
05
Assignment
Month
Assignment
Month
FF2
Position or rank
A-39
05
04
Day
04
Day
2005
Year
2005
Year
NFIRS 5.0 Self-Study Program
A
MM
VA
92188
FDID
DD
05
YYYY
03
2005
Incident Date
State
Station
Alternate Location Specification
B
37
55
•
77
Longitude
•
44
OR
North
South
•
Township
East
West
1
2
3
4
5
6
7
X
Range
D2
Subsection
Meridian
1
2
3
4
5
6
7
Area Type
C
X
1
2
3
4
Rural, farms >50 acres
Urban (heavily populated)
Rural/urban or suburban
Urban-wildland interface area
Weather Information
H
3
62
10
Wind Speed (mph)
70
East
Wind Direction
Weather Type
%
Relative Humidity
F°
Check if
negative
2
%
Fuel Moisture
Moderate
Fire Danger
I3
0
F
Mobile Property Type
G
Equipment Involved
in Ignition
43
643
None
Hot ember or ash
None
Grill, hibachi, barb
Primary Crops Burned
I4
Identify up to 3 crops if any crops were burned
None
Crop 1
Total Acres Burned
,
1•0
,
NFDRS Fuel Model at Origin
K
Crop 3
M
Type of Right-of-Way
X None
Required if less than 100 feet
Enter the code and the descriptor corresponding
to the NFDRS Fuel Model at Origin
Feet
Horizontal distance
from right-of-way
Type of right-of-way
% Total Acres Burned
Person Responsible for Fire
L1
U
Heat Source
Number of Buildings Threatened
Fire Danger Rating
Indicate the percent of the total acres burned for each ownership type then check the ONE box to identify the property ownership at the origin of the fire. If the ownership at origin is Federal,
enter the Federal Agency Code.
Ownership
None
E
Crop 2
Property Management
J
Number of Buildings Ignited
0
#2
Number of buildings that were threatened by
Wildland fire but were not involved
Air Temperature
15
I2
X None
#3
X None
Number of buildings that were
ignited in Wildland fire
Clear, less than
1/10 cloud
10
#2
Fire Suppression Factors
D4
Enter
up to
three
factors
Asleep
Possibly impaired by alcohol or drugs
Unattended person
Possibly mentally disabled
Physically disabled
Multiple persons involved
Age was a factor
NFDRS Weather Station ID
High Wind
None
#1
Human Factors Contributing
to Ignition
I1
61
#1
NFIRS–8
Wildland
Fire
Factors Contributing
to Ignition
D3
Check as many boxes as are applicable.
Section
Change
Exposure
Misuse of fire
Other
Undetermined
8
Natural source
0
Equipment
U
Smoking
Open/outdoor fire
Debris/vegetation burn
Structure (exposure)
Incendiary
Delete
0
Incident Number
Wildland Fire Cause
D1
Enter Latitude/Longitude OR Township/Range/Section/Subsection
Meridian if Section B on the Basic Module is not completed
Latitude
0 0 0 5 4 5 5
Undetermined
N
Fire Behavior
%
1
2
3
Private
X
Identified person caused fire
Unidentified person caused fire
Fire not caused by person
These optional descriptors refer to observations
made at the point of initial attack
If person identified, complete the rest of Section L
1
2
Tax paying
Non-tax paying
Feet
%
%
L2
1
2
Public
3
4
5
6
X
City, town, village, local
County or parish
State or province
Federal
%
%
100
Foreign
Military
Other
L3
X
Male
Female
Relative position on slope
49
Aspect
Date of Birth
OR
Month
Day
Year
%
%
%
%
Elevation
Age or Date of Birth
Age in Years
%
Federal Agency Code
7
8
0
Gender of Person Involved
Feet
Flame length
L4
Activity of Person Involved
10
Picnicking
Activity of Person Involved
A-40
Chains per Hour
Rate of spread
NFIRS–8 Revision 01/01/04
NFIRS 5.0 Self-Study Program Appendix A
Apparatus or Resources
Module: NFIRS-9
Scenario 9-2 Answers
A-41
NFIRS 5.0 Self-Study Program
A 92188
FDID
B
C
MM
VA
YYYY
01
2005
Station
Prefix
Exposure
Apt./Suite/Room
Basic
No Activity
0501-10
Census Tract
ST
Street or Highway
Street Type
Brunswick
VA
City
23351
State
Suffix
-
ZIP Code
Cross Street, Directions or National Grid, as applicable
Incident Type
X None
Aid Given or Received
Dates and Times
E1
Building fires
Incident Type
D
Incident Number
NFIRS–1
Change
Cary
E
5
Number/Milepost
Delete
000
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
111
0 0 0 5 4 3 3
Incident Date
State
Location Type
X
DD
05
Midnight is 0000
Month
Check boxes if
dates are the
same as Alarm
Date.
Day
ALARM always required
05
Alarm
01
Year
Hour
2005
Shifts and Alarms
E2
Min
Local Option
A
1253
Shift or
Platoon
Alarms
A12
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
Controlled
Last Unit
Cleared
Actions Taken
11
Suppression
Additional Action Taken (2)
EMS
Other
Additional Action Taken (3)
Civilian Fire Cas.–4
Fire Service Cas.–5
EMS–6
HazMat–7
Wildland Fire–8
Apparatus–9
Personnel–10
Arson–11
05
H1
Casualties
None
Deaths Injuries
Fire
Service
Civilian
H2
1
2
U
X
Special Studies
Local Option
0
0
0
1
Detector
Required for confined fires.
Detector alerted occupants
Detector did not alert them
Unknown
341
342
361
419
429
439
449
459
464
519
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
H3
1
2
3
4
5
6
7
8
0
1325
01 2005
G2
Personnel
3
0
0
12
0
0
Check box if resource counts include aid
received resources.
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
J
05
Apparatus
Salvage & Overhaul
Fire–2
Structure Fire–3
E3
1440
Special
Study Value
Estimated Dollar Losses and Values
LOSSES:
Required for all fires if known.
Optional for non-fires.
Property
$
,
Contents
$
,
None
24 , 000
9 , 600
PRE-INCIDENT VALUE: Optional
Property
$
Contents
$
X
Hazardous Materials Release
161 , 000
80 , 400
,
,
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.)
X
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.
Extinguish
Completed Modules
1258
01 2005
Resources
G1
Primary Action Taken (1)
12
01 2005
CONTROLLED optional, except for wildland fires
Their
State
Their Incident Number
F
05
Arrival
I
Mixed Use
Property
10
20
33
40
51
53
58
59
60
63
65
00
X
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
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
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
A-42
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
K1
Local Option
Business Name (if applicable)
Check this box if same
address as incident
Location (Section B).
Then skip the three
duplicate address
lines.
X
Area Code
Christy
A
First Name
Mr., Ms., Mrs.
Phone Number
Gordon
MI
Last Name
Suffix
East Cary
5
Number
Prefix
S t
Street or Highway
Street Type
Suffix
Brunswick
Post Office Box
VA
Apt./Suite/Room
City
23351
State
ZIP Code
More people involved? Check this box and attach Supplemental Forms (NFIRS–1S) as necessary.
as person involved?
X Same
Then check this box and skip
Owner
K2
Local Option
Check this box if same
address as incident
Location (Section B).
Then skip the three
duplicate address
lines.
the rest of this block.
Mr., Ms., Mrs.
Business Name (if applicable)
First Name
Number
MI
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:
L
Local Option
Mrs. Christy A. Gordon was warming her lunch on the stove
when the grease from the pan began to burn.
Fire Module Required?
Check the box that applies and then complete the Fire Module
based on Incident Type, as follows:
Complete Fire & Structure Modules
Complete Fire Module &
Section I, Structure Module
Basic Module Only
Confined 113–118
Complete Fire Module
Mobile property 120–123
Complete Fire Module
Vehicle 130–138
Complete Fire or Wildland Module
Vegetation 140–143
Outside rubbish fire 150–155 Basic Module Only
Complete Fire or Wildland Module
Special outside fire 160
Special outside fire 161–163 Complete Fire Module
Complete Fire or Wildland Module
Crop fire 170–173
Buildings 111
Special structure 112
ITEMS WITH A
MUST ALWAYS BE COMPLETED!
More remarks? Check this box and attach Supplemental Forms (NFIRS–1S) as necessary.
M
Authorization
Check box if
same as
Officer in
charge.
105
Officer in charge ID
Tonya Gordon
Signature
224
Member making report ID
Captain
Position or rank
Adam Wallner
Signature
05
Assignment
Month
Assignment
Month
FF1
Position or rank
A-43
05
01
Day
01
Day
2005
Year
2005
Year
NFIRS 5.0 Self-Study Program
A
92188
FDID
B
MM
DD
05
VA
YYYY
01
0 0 0 5 4 3 3
2005
Incident Date
State
Station
Property Details
C
1
B1
Not Residential
Incident Number
On-Site Materials
or Products
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
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
Estimated number of residential living units in
building of origin whether or not all units
became involved
1
B2
Buildings not involved
Number of buildings involved
B3
X
,
None
Less than one acre
Acres burned (outside fires)
On-site material (3)
D
Ignition
E1
D1 2 4 Cooking area, kitchen
1
2
3
4
5
U
Area of fire origin
D2
1 1 Spark, ember or flame
Heat source
D3 1 2
Radiated/conducted heat
from operating equipment
Item first ignited
D4
1
Skip to
Section G
Check box if this is an exposure report.
X
Intentional
Unintentional
Failure of equipment or heat source
Act of nature
Cause under investigation
Cause undetermined after investigation
E3
1
2
Equipment unattended
None
F2
1
6 4 6 Range with or without oven
Equipment Involved
Serial #
Whirlpool
RF330PXVN
F925888840
Year
2000
Brand
Model
H1
Mobile Property Involved
1
Not involved in ignition, but burned
2
Involved in ignition, but did not burn
3
Involved in ignition and burned
Equipment Power Source
Equipment Portability
Fire Suppression Factors
Female
X None
Enter up to three codes.
2
X
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.
H2
Fire suppression factor (1)
Portable
1
None
2
Male
Equipment Power Source
F3
X
G
2 1 Natural Gas or other
If equipment was not involved, skip to
Section G
Age was a factor
Estimated age of
person involved
Required only if item first
ignited code is 00 or <70
Equipment Involved in Ignition
None
Possibly impaired by
alcohol or drugs
Unattended person
Possibly mentally disabled
Physically disabled
Multiple persons involved
7
Factor contributing to ignition (1)
Factor contributing to ignition (2)
F1
Human Factors
Contributing to Ignition
X Asleep
3
4
5
None
6
Factors Contributing to Ignition
53
2 7 Cooking oil
Type of material first ignited
Cause of Ignition
Check all applicable boxes
E2
Check box if fire spread was
confined to object of origin.
Fire
Change
Exposure
X None
NFIRS–2
Delete
0
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
A-44
NFIRS 5.0 Self-Study Program
Structure Type
I1
If fire was in an enclosed building or a
portable/mobile structure, complete the
rest of this form.
X Enclosed building
1
2
3
4
5
6
7
8
0
Portable/mobile structure
Open structure
Air-supported structure
Tent
Open platform (e.g., piers)
Underground structure (work areas)
Connective structure (e.g., fences)
Other type of structure
Fire Origin
J1
1
I2
Building Status
1
2
3
4
5
6
7
0
U
Under construction
Occupied & operating
Idle, not routinely used
Under major renovation
Vacant and secured
Vacant and unsecured
Being demolished
Other
Undetermined
J3
Below grade
Story of
fire origin
Fire Spread
J2
2
3
4
5
If fire spread was confined to object of origin,
do not check a box (Ref. Block D3, Fire Module).
X Confined to room of origin
Confined to floor of origin
Confined to building of origin
Beyond building of origin
Presence of Detectors
L1
1
U
None Present
X
Skip to
Section M
Present
Undetermined
Detector Type
L2
X
1
2
3
4
5
0
U
M1
Smoke
Heat
Combination smoke and heat
Sprinkler, water flow detection
More than one type present
Other
Undetermined
1
2
3
4
5
6
7
0
U
Number of stories w/significant damage
(25 to 49% flame damage)
0
Number of stories w/heavy damage
(50 to 74% flame damage)
0
Number of stories w/extreme damage
(75 to 100% flame damage)
Detector Power Supply
L4
Detector Operation
1
Fire too small to activate
X
Operated
Complete
Block L5
3
Failed to operate
Complete
Block L6
U
Undetermined
2
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
M3
,
K
Check if no flame spread OR if
same as Material First Ignited (Block D4,
Fire Module) OR if unable to determine.
K1
Skip to
Section L
Item contributing most to flame spread
K2
Type of material contributing
most to flame spread
1
2
Detector Effectiveness
X
3
4
U
L6
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
Number of Sprinkler
Heads Operating
Required if system operated
Required only if item
contributing code is 00 or <70.
Required if detector operated.
Operated/effective (go to M4)
Operated/not effective (go to M4)
Fire too small to activate
Failed to operate (go to M5)
Other
Undetermined
M4
Width in feet
Type of Material Contributing Most
to Flame Spread
M5
Required if fire was within designed range
1
2
3
4
0
U
,
BY
Length in feet
L5
Battery only
Hardwire only
Plug-in
Hardwire with battery
Plug-in with battery
Mechanical
Multiple detectors & power
supplies
Other
Undetermined
0
U
1 , 0 0 0
,
Total square feet
0
Total number of stories
below grade
0
X
NFIRS–3
Structure
Fire
OR
Number of stories w/minor damage
(1 to 24% flame damage)
Type of Automatic Extinguishing System
Required if fire was within designed range of AES
2
Total number of stories at or
above grade
1
1
2
3
4
5
6
7
Main Floor Size
I4
Count the roof as part of the
highest story.
Count the roof as part of the highest story.
Presence of Automatic Extinguishing System
N X None Present
Present
1
Complete rest of
Section M
2
Partial System Present
U
Undetermined
M2
Building
Height
Number of Stories Damaged by Flame
L3
(In area of the fire)
N
X
I3
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
A-45
Revision 01/01/06
NFIRS 5.0 Self-Study Program
A
92188
FDID
B
MM
VA
05
ID
Type
2
ID
Type
3
ID
Type
4
Eng1
11
Truck
12
Eng2
11
ID
Type
5
ID
Type
6
ID
Type
7
ID
Type
8
ID
Type
9
ID
Type
Arrival
Clear
0 5 0 1 2005 1253
0 5 0 1 2005 1258
0 5 0 1 2005 1440
X
4
Dispatch
Arrival
Clear
0 5 0 1 2005 1253
0 5 0 1 2005 1258
0 5 0 1 2005 1440
X
4
Dispatch
0 5 0 1 2005 1253
0 5 0 1 2005 1300
0 5 0 1 2005 1440
Arrival
Clear
X
Day
Year
Hour/Min
Sent
0
Apparatus Use
Check ONE box for each
apparatus to indicate its main
use at the incident.
X
X
4
X
Dispatch
Dispatch
Dispatch
Dispatch
Dispatch
11
Suppression
EMS
Other
Arrival
Clear
Dispatch
Suppression
EMS
Other
Arrival
Clear
21 Dozer or plow
22 Tractor
24 Tanker or tender
20 Heavy ground equipment, other
12
Suppression
EMS
Other
Arrival
Clear
Heavy Ground Equipment
Suppression
EMS
Other
11
Suppression
EMS
Other
Arrival
Clear
11 Engine
12 Truck or aerial
13 Quint
14 Tanker and pumper combination
16 Brush truck
17 ARFF (aircraft rescue and firefighting)
10 Ground fire suppression, other
Suppression
EMS
Other
Actions Taken
List up to 4 actions for each
apparatus.
Suppression
EMS
Other
Arrival
Clear
Ground Fire Suppression
Suppression
EMS
Other
Apparatus or
Resources
Suppression
EMS
Other
Arrival
Clear
Apparatus or Resource Type
Change
Exposure
X
Month
Dispatch
Incident Number
Number
of
People
Midnight is 0000
Check if same date as Alarm date on
the Basic Module (Block E1)
Use codes listed below
1
0 0 0 5 4 3 3
Station
Dates and Times
NFIRS–9
Delete
YYYY
2005
Incident Date
State
Apparatus or
Resources
DD
01
Medical and Rescue
Aircraft
41 Aircraft: fixed-wing tanker
42 Helitanker
43 Helicopter
40 Aircraft, other
Marine Equipment
51 Fire boat with pump
52 Boat, no pump
50 Marine equipment, other
Support Equipment
61 Breathing apparatus support
62 Light and air unit
60 Support apparatus, other
A-46
71 Rescue unit
72 Urban search and rescue unit
73 High-angle rescue unit
75 BLS unit
76 ALS unit
70 Medical and rescue unit, other
More apparatus?
Use additional
sheets.
Other
91 Mobile command post
92 Chief officer car
93 HazMat unit
94 Type I hand crew
95 Type II hand crew
99 Privately owned vehicle
00 Other apparatus/resources
NN None
UU Undetermined
NFIRS–9
Revision 01/01/04
NFIRS 5.0 Self-Study Program Appendix A
Personnel Module:
NFIRS-10
Scenario 10-2 Answers
A-47
NFIRS 5.0 Self-Study Program
A 92188
FDID
B
C
MM
VA
YYYY
01
2005
Station
Prefix
Incident Number
NFIRS–1
Change
Exposure
Basic
No Activity
5011-12
Census Tract
ST
Street or Highway
Street Type
Brunswick
Apt./Suite/Room
Delete
000
Cary
E
5
Number/Milepost
VA
City
23351
State
Suffix
-
ZIP Code
Cross Street, Directions or National Grid, as applicable
Incident Type
Midnight is 0000
Month
Check boxes if
dates are the
same as Alarm
Date.
X None
Aid Given or Received
Dates and Times
E1
Building Fires
Incident Type
D
0 0 0 5 4 3 3
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
111
002
Incident Date
State
Location Type
X
DD
05
Day
ALARM always required
05
Alarm
01
Year
Hour
2005
E2
Min
Shifts and Alarms
Local Option
A
1253
Shift or
Platoon
Alarms
A12
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
Controlled
Last Unit
Cleared
Actions Taken
11
Suppression
Additional Action Taken (2)
EMS
Other
Additional Action Taken (3)
Civilian Fire Cas.–4
Fire Service Cas.–5
EMS–6
HazMat–7
Wildland Fire–8
Apparatus–9
Personnel–10
Arson–11
05
H1
Casualties
X
None
Deaths Injuries
Fire
Service
Civilian
H2
1
2
U
X
Special Studies
Local Option
Detector
Required for confined fires.
Detector alerted occupants
Detector did not alert them
Unknown
341
342
361
419
429
439
449
459
464
519
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
H3
1
2
3
4
5
6
7
8
0
1325
01 2005
G2
Personnel
3
0
0
12
0
0
Check box if resource counts include aid
received resources.
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
J
05
Apparatus
Ventilate
Fire–2
Structure Fire–3
E3
1440
Special
Study Value
Estimated Dollar Losses and Values
LOSSES:
Required for all fires if known.
Optional for non-fires.
Property
$
,
Contents
$
,
24 , 000
9 , 600
None
PRE-INCIDENT VALUE: Optional
Property
$
Contents
$
X
Hazardous Materials Release
161 , 000
, 80 , 400
,
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.)
X
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.
Extinguish
Completed Modules
1305
01 2005
Resources
G1
Primary Action Taken (1)
51
01 2005
CONTROLLED optional, except for wildland fires
Their
State
Their Incident Number
F
05
Arrival
I
Mixed Use
Property
10
20
33
40
51
53
58
59
60
63
65
00
X
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
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
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
A-48
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
K1
Local Option
Business Name (if applicable)
Check this box if same
address as incident
Location (Section B).
Then skip the three
duplicate address
lines.
X
Area Code
Christy
A
First Name
Mr., Ms., Mrs.
Phone Number
Gordon
MI
Last Name
Suffix
East Cary
5
Number
Prefix
ST
Street or Highway
Street Type
Suffix
Brunswick
Post Office Box
VA
Apt./Suite/Room
City
23351
State
ZIP Code
More people involved? Check this box and attach Supplemental Forms (NFIRS–1S) as necessary.
as person involved?
X Same
Then check this box and skip
Owner
K2
Local Option
Check this box if same
address as incident
Location (Section B).
Then skip the three
duplicate address
lines.
the rest of this block.
Mr., Ms., Mrs.
Business Name (if applicable)
First Name
Number
MI
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:
L
Local Option
Mrs. Christy A. Gordon was warming her lunch on the stove
when the grease from the pan began to burn.
Fire Module Required?
Check the box that applies and then complete the Fire Module
based on Incident Type, as follows:
Complete Fire & Structure Modules
Complete Fire Module &
Section I, Structure Module
Basic Module Only
Confined 113–118
Complete Fire Module
Mobile property 120–123
Complete Fire Module
Vehicle 130–138
Complete Fire or Wildland Module
Vegetation 140–143
Outside rubbish fire 150–155 Basic Module Only
Complete Fire or Wildland Module
Special outside fire 160
Special outside fire 161–163 Complete Fire Module
Complete Fire or Wildland Module
Crop fire 170–173
Buildings 111
Special structure 112
ITEMS WITH A
MUST ALWAYS BE COMPLETED!
More remarks? Check this box and attach Supplemental Forms (NFIRS–1S) as necessary.
M
Authorization
Check box if
same as
Officer in
charge.
105
Officer in charge ID
Tonya Gordon
Signature
224
Member making report ID
Captain
Position or rank
Adam Wallner
Signature
05
Assignment
Month
Assignment
Month
FF1
Position or rank
A-49
05
01
Day
01
Day
2005
Year
2005
Year
NFIRS 5.0 Self-Study Program
A
92188
FDID
B
MM
DD
05
VA
YYYY
01
Incident Date
State
Station
Property Details
C
1
B1
0 0 0 5 4 3 3
002
2005
Not Residential
Incident Number
On-Site Materials
or Products
None
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
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
Estimated number of residential living units in
building of origin whether or not all units
became involved
1
B2
Buildings not involved
Number of buildings involved
B3
None
,
Less than one acre
Acres burned (outside fires)
On-site material (3)
D
Ignition
E1
D1 2 4 Cooking area, kitchen
Area of fire origin
D2
8 1 Heat from direct flame
Heat source
1
2
3
4
5
U
D4
confined to object of origin.
Skip to
Section G
Check box if this is an exposure report.
X
Intentional
Unintentional
Failure of equipment or heat source
Act of nature
Cause under investigation
Cause undetermined after investigation
Factors Contributing to Ignition
Equipment unattended
53
2 7 Cooking oil
Type of material first ignited
Cause of Ignition
E3
1
2
None
1
6 4 6 Range with or without oven
Equipment Involved
Serial #
Whirlpool
RF330PXVN
F925888840
Year
2000
Brand
Model
H1
Mobile Property Involved
1
Not involved in ignition, but burned
2
Involved in ignition, but did not burn
3
Involved in ignition and burned
Equipment Power Source
2
Male
Fire Suppression Factors
Female
X None
Enter up to three codes.
Equipment Power Source
F3
Equipment Portability
2
X
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.
H2
Fire suppression factor (1)
Portable
1
X None
G
2 1 Natural Gas or other
If equipment was not involved, skip to
Section G
Age was a factor
Estimated age of
person involved
Required only if item first
ignited code is 00 or <70
F2
Possibly impaired by
alcohol or drugs
Unattended person
Possibly mentally disabled
Physically disabled
Multiple persons involved
7
Factor contributing to ignition (1)
Equipment Involved in Ignition
None
X Asleep
3
4
5
None
6
Factor contributing to ignition (2)
F1
Human Factors
Contributing to Ignition
Check all applicable boxes
D3 7 6 Cooking materials, incl E2
Item first ignited
Check box if fire spread was
1
Fire
Change
Exposure
X
NFIRS–2
Delete
0
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
A-50
NFIRS 5.0 Self-Study Program
Structure Type
I1
If fire was in an enclosed building or a
portable/mobile structure, complete the
rest of this form.
X
1
2
3
4
5
6
7
8
0
Enclosed building
Portable/mobile structure
Open structure
Air-supported structure
Tent
Open platform (e.g., piers)
Underground structure (work areas)
Connective structure (e.g., fences)
Other type of structure
Fire Origin
J1
1
I2
Building Status
1
2
3
4
5
6
7
0
U
Under construction
Occupied & operating
Idle, not routinely used
Under major renovation
Vacant and secured
Vacant and unsecured
Being demolished
Other
Undetermined
J3
Below grade
Story of
fire origin
Fire Spread
J2
2
3
4
5
If fire spread was confined to object of origin,
do not check a box (Ref. Block D3, Fire Module).
X Confined to room of origin
Confined to floor of origin
Confined to building of origin
Beyond building of origin
Presence of Detectors
L1
1
U
X
Skip to
Section M
Present
Undetermined
Detector Type
L2
1
2
3
4
5
0
U
None Present
X
M1
Smoke
Heat
Combination smoke and heat
Sprinkler, water flow detection
More than one type present
Other
Undetermined
1
2
3
4
5
6
7
0
U
Number of stories w/significant damage
(25 to 49% flame damage)
0
Number of stories w/heavy damage
(50 to 74% flame damage)
0
Number of stories w/extreme damage
(75 to 100% flame damage)
Detector Power Supply
L4
Detector Operation
1
Fire too small to activate
X
Operated
Complete
Block L5
3
Failed to operate
Complete
Block L6
U
Undetermined
2
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
M3
,
K
Check if no flame spread OR if
same as Material First Ignited (Block D4,
Fire Module) OR if unable to determine.
K1
Skip to
Section L
Item contributing most to flame spread
K2
Type of material contributing
most to flame spread
1
2
Detector Effectiveness
X
3
4
U
L6
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
Number of Sprinkler
Heads Operating
Required if system operated
Required only if item
contributing code is 00 or <70.
Required if detector operated.
Operated/effective (go to M4)
Operated/not effective (go to M4)
Fire too small to activate
Failed to operate (go to M5)
Other
Undetermined
M4
Width in feet
Type of Material Contributing Most
to Flame Spread
M5
Required if fire was within designed range
1
2
3
4
0
U
,
BY
Length in feet
L5
Battery only
Hardwire only
Plug-in
Hardwire with battery
Plug-in with battery
Mechanical
Multiple detectors & power
supplies
Other
Undetermined
0
U
2 , 0 0 0
,
Total square feet
0
Total number of stories
below grade
0
X
NFIRS–3
Structure
Fire
OR
Number of stories w/minor damage
(1 to 24% flame damage)
Type of Automatic Extinguishing System
Required if fire was within designed range of AES
2
Total number of stories at or
above grade
1
1
2
3
4
5
6
7
Main Floor Size
I4
Count the roof as part of the
highest story.
Count the roof as part of the highest story.
Presence of Automatic Extinguishing System
N X None Present
Present
1
Complete rest of
Section M
2
Partial System Present
U
Undetermined
M2
Building
Height
Number of Stories Damaged by Flame
L3
(In area of the fire)
N
X
I3
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
A-51
Revision 01/01/06
NFIRS 5.0 Self-Study Program
A
92188
FDID
B
MM
VA
05
ID
Type
Dates and Times
Eng1
11
Dispatch
Arrival
Clear
Type
Truck
12
Dispatch
Arrival
Clear
Type
Eng2
11
Dispatch
Arrival
Clear
Personnel
ID
FF
FF
FF
Capt
Rank or
Grade
FF
Capt
FF
FF
0 5 0 1 2005 1253
0 5 0 1 2005 1300
0 5 0 1 2005 1440
Name
222
219
007
234
Rank or
Grade
0 5 0 1 2005 1253
0 5 0 1 2005 1258
0 5 0 1 2005 1440
Mills, Juan
Fritz, Marion
Harris, Ronald
Heilig, Cal
Kritz, Paul
Long, Andy
Baron, Stan
Mack, John
Sent
X
Hour/Min
0 5 0 1 2005 1253
0 5 0 1 2005 1258
0 5 0 1 2005 1440
Name
317
847
299
356
ID
Year
Walner, Andrew
Winer, Karen
Starwood, Andrew
Gordon, Tonya
Personnel
ID
3
Midnight is 0000
Name
224
111
130
105
ID
Incident Number
Check if same date as Alarm date on
the Basic Module (Block E1)
Personnel
ID
2
0 0 0 5 4 3 3
Station
Month Day
1
YYYY
2005
Incident Date
State
Apparatus or
Resources
DD
01
Exposure
Number
of
People
Sent
X
Attend
X
X
X
X
X
Sent
X
Attend
X
X
X
X
X
4
Delete
NFIRS–10
Change
Personnel
Apparatus Use
Actions Taken
Check ONE box for each
apparatus to indicate its main
use at the incident.
List up to 4 actions for
each apparatus and
each personnel.
X
Suppression
EMS
Other
Action
Taken
Action
Taken
11
11
58
81
11
81
Action
Taken
X
Suppression
EMS
Other
Action
Taken
Action
Taken
Action
Taken
51
12
81
Action
Taken
Action
Taken
51
81
58
12
4
Rank or
Grade
Attend
X
Action
Taken
FF
FF
Capt
FF
X
X
X
X
11
11
81
58
X
Suppression
EMS
Other
Action
Taken
11
58
81
Action
Taken
NFIRS–10
A-52
51
51
51
4
Sent
X
0
Action
Taken
Revision 01/01/04
NFIRS 5.0 Self-Study Program Appendix A
Arson and Juvenile
Firesetter Module:
NFIRS-11
Scenario 11-2 Answers
A-53
NFIRS 5.0 Self-Study Program
A 92188
FDID
B
C
MM
AZ
YYYY
25
2005
Station
Incident Number
Prefix
Exposure
Basic
No Activity
0501-10
Census Tract
ST
Street or Highway
Street Type
Queen Creek
Apt./Suite/Room
NFIRS–1
Change
Main
222
Number/Milepost
AZ
City
85242
State
Suffix
-
ZIP Code
Cross Street, Directions or National Grid, as applicable
Incident Type
Midnight is 0000
Month
Check boxes if
dates are the
same as Alarm
Date.
X None
Aid Given or Received
Dates and Times
E1
Building Fires
Incident Type
D
Delete
0
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
111
0 4 4 4 9 9 9
Incident Date
State
Location Type
X
DD
06
Day
ALARM always required
06
Alarm
25
Year
Hour
2005
E2
Min
Shifts and Alarms
Local Option
C
1500
Shift or
Platoon
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
Controlled
Last Unit
Cleared
Actions Taken
11
Extinguish
Suppression
EMS
Investigate
Other
Additional Action Taken (3)
Fire–2
Structure Fire–3
Civilian Fire Cas.–4
Fire Service Cas.–5
EMS–6
HazMat–7
Wildland Fire–8
Apparatus–9
Personnel–10
Arson–11
06
H1
Casualties
X
None
Deaths Injuries
Fire
Service
Civilian
H2
1
2
U
Special Studies
Local Option
Detector
Required for confined fires.
Detector alerted occupants
Detector did not alert them
X Unknown
H3
1
2
3
4
5
6
7
8
0
1545
25 2005
G2
Personnel
3
0
0
13
0
0
Check box if resource counts include aid
received resources.
341
342
361
419
429
439
449
459
464
519
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
X
Special
Study ID#
1700
Special
Study Value
Estimated Dollar Losses and Values
LOSSES:
Required for all fires if known.
Optional for non-fires.
Property
$
,
Contents
$
,
None
30 , 000
,
PRE-INCIDENT VALUE: Optional
Property
$
,
,
Contents
$
,
,
X
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.)
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
J
06
Apparatus
Salvage & overhaul
Completed Modules
E3
LAST UNIT CLEARED, required except for wildland fires
Check this box and skip this block if an
Apparatus or Personnel Module is used.
Additional Action Taken (2)
86
1507
25 2005
Resources
G1
Primary Action Taken (1)
12
25 2005
CONTROLLED optional, except for wildland fires
Their
State
Their Incident Number
F
06
Arrival
I
Mixed Use
Property
10
20
33
40
51
53
58
59
60
63
65
00
X
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
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
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
A-54
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
K1
Local Option
Business Name (if applicable)
Check this box if same
address as incident
Location (Section B).
Then skip the three
duplicate address
lines.
X
Area Code
Stash
First Name
Mr., Ms., Mrs.
Phone Number
Stable
MI
Last Name
ST
Main
222
Number
Street or Highway
Prefix
Street Type
Suffix
Suffix
Queen Creek
Post Office Box
AZ
Apt./Suite/Room
City
85242
State
ZIP Code
More people involved? Check this box and attach Supplemental Forms (NFIRS–1S) as necessary.
as person involved?
X Same
Then check this box and skip
Owner
K2
Local Option
Check this box if same
address as incident
Location (Section B).
Then skip the three
duplicate address
lines.
the rest of this block.
Mr., Ms., Mrs.
Business Name (if applicable)
First Name
Number
MI
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:
L
Local Option
Fire Module Required?
Check the box that applies and then complete the Fire Module
based on Incident Type, as follows:
Complete Fire & Structure Modules
Complete Fire Module &
Section I, Structure Module
Basic Module Only
Confined 113–118
Complete Fire Module
Mobile property 120–123
Complete Fire Module
Vehicle 130–138
Complete Fire or Wildland Module
Vegetation 140–143
Outside rubbish fire 150–155 Basic Module Only
Complete Fire or Wildland Module
Special outside fire 160
Special outside fire 161–163 Complete Fire Module
Complete Fire or Wildland Module
Crop fire 170–173
Buildings 111
Special structure 112
ITEMS WITH A
MUST ALWAYS BE COMPLETED!
More remarks? Check this box and attach Supplemental Forms (NFIRS–1S) as necessary.
M
Authorization
Check box if
same as
Officer in
charge.
333
Joe Mill
Captain
Officer in charge ID
Signature
Position or rank
Assignment
Month
Day
Year
Member making report ID
Signature
Position or rank
Assignment
Month
Day
Year
X
A-55
NFIRS 5.0 Self-Study Program
A
92188
FDID
B
MM
DD
06
AZ
YYYY
25
0 4 4 4 9 9 9
2005
Incident Date
State
Station
Property Details
C
1
B1
Not Residential
Incident Number
On-Site Materials
or Products
None
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
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
Estimated number of residential living units in
building of origin whether or not all units
became involved
1
B2
Buildings not involved
Number of buildings involved
B3
X
,
None
Less than one acre
Acres burned (outside fires)
On-site material (3)
D
Ignition
E1
D1 2 1 Bedroom < 5 persons
1
2
3
4
5
U
Area of fire origin
4 Match
D2 Heat6 source
D3 6 5 Flammable liquid/gas
Item first ignited
1
Check box if fire spread was
confined to object of origin.
E2
Type of material first ignited
Cause of Ignition
Skip to
Section G
Check box if this is an exposure report.
Check all applicable boxes
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
X None
F2
X Age was a factor
16
Estimated age of
person involved
Factor contributing to ignition (1)
Required only if item first
ignited code is 00 or <70
Equipment Involved in Ignition
None
Asleep
Possibly impaired by
alcohol or drugs
Unattended person
Possibly mentally disabled
Physically disabled
Multiple persons involved
1
2
1
Factor contributing to ignition (2)
F1
Human Factors
Contributing to Ignition
E3
7
7 1 Fabric, fiber, cotton
D4
X
Fire
Change
Exposure
X
NFIRS–2
Delete
0
Equipment Power Source
G
X
2
Male
Fire Suppression Factors
Female
X None
Enter up to three codes.
If equipment was not involved, skip to
Section G
Equipment Power Source
Equipment Involved
F3
Brand
Model
Serial #
Equipment Portability
1
Portable
2
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
H1
Mobile Property Involved
1
Not involved in ignition, but burned
2
Involved in ignition, but did not burn
3
Involved in ignition and burned
X None
H2
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
A-56
NFIRS 5.0 Self-Study Program
Structure Type
I1
If fire was in an enclosed building or a
portable/mobile structure, complete the
rest of this form.
X
1
2
3
4
5
6
7
8
0
Enclosed building
Portable/mobile structure
Open structure
Air-supported structure
Tent
Open platform (e.g., piers)
Underground structure (work areas)
Connective structure (e.g., fences)
Other type of structure
Fire Origin
J1
2
I2
Building Status
1
2
3
4
5
6
7
0
U
Under construction
Occupied & operating
Idle, not routinely used
Under major renovation
Vacant and secured
Vacant and unsecured
Being demolished
Other
Undetermined
J3
Below grade
Story of
fire origin
Fire Spread
J2
2
3
4
5
If fire spread was confined to object of origin,
do not check a box (Ref. Block D3, Fire Module).
X
Confined to building of origin
Beyond building of origin
Presence of Detectors
L1
N
None Present
Present
1
U
Skip to
Section M
X
Undetermined
Detector Type
L2
1
2
3
4
5
0
U
Smoke
Heat
Combination smoke and heat
Sprinkler, water flow detection
More than one type present
Other
Undetermined
M1
Number of stories w/significant damage
(25 to 49% flame damage)
1
Number of stories w/heavy damage
(50 to 74% flame damage)
0
Number of stories w/extreme damage
(75 to 100% flame damage)
Detector Power Supply
L4
Detector Operation
1
Fire too small to activate
2
Operated
Complete
Block L5
3
Failed to operate
Complete
Block L6
U
Undetermined
1
2
3
4
5
6
7
0
U
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
,
K
Check if no flame spread OR if
same as Material First Ignited (Block D4,
Fire Module) OR if unable to determine.
K1
Skip to
Section L
Item contributing most to flame spread
K2
Type of material contributing
most to flame spread
1
2
3
4
U
L6
Detector Effectiveness
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
Number of Sprinkler
Heads Operating
Required if system operated
Required only if item
contributing code is 00 or <70.
Required if detector operated.
Operated/effective (go to M4)
Operated/not effective (go to M4)
Fire too small to activate
Failed to operate (go to M5)
Other
Undetermined
M4
Width in feet
Type of Material Contributing Most
to Flame Spread
M5
Required if fire was within designed range
1
2
3
4
0
U
,
BY
Length in feet
L5
Battery only
Hardwire only
Plug-in
Hardwire with battery
Plug-in with battery
Mechanical
Multiple detectors & power
supplies
Other
Undetermined
M3
1 , 6 0 0
,
Total square feet
0
Total number of stories
below grade
0
0
U
NFIRS–3
Structure
Fire
OR
Number of stories w/minor damage
(1 to 24% flame damage)
Presence of Automatic Extinguishing System
None Present
N
Present
1
Complete rest of
Section M
2
Partial System Present
U X Undetermined
M2
2
Total number of stories at or
above grade
0
1
2
3
4
5
6
7
Main Floor Size
I4
Count the roof as part of the
highest story.
Count the roof as part of the highest story.
L3
(In area of the fire)
Building
Height
Number of Stories Damaged by Flame
Confined to room of origin
X Confined to floor of origin
I3
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
A-57
Revision 01/01/06
NFIRS 5.0 Self-Study Program
A 92188
FDID
AZ
State
MM
25
YYYY
0 4 4 4 9 9 9
2005
Incident Date
Agency Referred To
B
DD
06
Station
Incident Number
NFIRS–11
Arson
Delete
0
Change
Exposure
None
Street address
Their case number
Agency name
City
Their ORI
Agency phone number
State
Arizona Child Welfare
Case Status
1 X Investigation open
Investigation closed
2
Investigation inactive
3
C
11
12
13
14
15
21
F
Extortion
Labor unrest
Insurance fraud
Intimidation
Void contract/lease
Personal
22
23
24
31
32
41
Hate crime
Institutional
Societal
Protest
Civil unrest
Fireplay/curiosity
None
Check up to three factors
G1
Terrorist group
Gang
Anti-government group
Outlaw motorcycle organization
Organized crime
Racial/ethnic hate group
Religious hate group
Sexual preference hate group
Other group
Unknown
Entry Method
Availability of Material First Ignited
1
2
U
Transported to scene
Available at scene
Unknown
X
42
43
44
45
51
52
53
X
H
Incendiary Devices
11
12
13
Bottle (glass)
Bottle (plastic)
Jug
11
12
13
14
15
16
Wick or fuse
Candle
Cigarette and matchbook
Electronic component
Mechanical device
Remote control
Burglary
Homicide concealment
Burglary concealment
Auto theft concealment
Destroy records/evidence
Other suspected motivation
Unknown motivation
54
61
62
63
64
00
UU
Vanity/recognition
Thrills
Attention/sympathy
Sexual excitement
Homicide
Suicide
Domestic violence
No container
CONTAINER
Select one from each category
Extent of Fire Involvement on Arrival
No device
IGNITION/DELAY DEVICE
11
12
14
15
Box
Other Container
Unknown
Pressurized container 17
00
Can (not gas or fuel)
Gasoline or fuel can UU
14
15
16
17
18
19
20
00
UU
Road flare/fuse
Chemical component
Trailer/streamer
Open flame source
Other delay device
Unknown
None
FUEL
Entry Method
G2
D
Check up to three factors
Apparent Group Involvement
1
2
3
4
5
6
7
8
0
U
Their FDID
Their Federal Identifier (FID)
Closed with arrest
Closed with exceptional
clearance
4
5
Suspected Motivation Factors
E
ZIP code
Ordinary combustibles
Flammable gas
Ignitable liquid
Ignitable solid
16
17
00
UU
Pyrotechnic material
Explosive material
Other material
Unknown
Extent of Fire Involvement
I
Other Investigative Information
J
Property Ownership
K
Initial Observations
Check all that apply
Check all that apply
1
2
3
4
5
6
7
8
Code violations
Structure for sale
Structure vacant
Other crimes involved
Illicit drug activity
Change in insurance
Financial problem
Criminal/civil actions pending
1
2
3
4
5
6
7
0
Private
City, town, village, local
County or parish
State or province
Federal
Foreign
Military
Other
1
2
3
4
L
1
2
Windows ajar 5
Doors ajar
6
Doors locked 7
Doors unlocked 8
Fire department forced entry
Entry forced prior to FD arrival
Security system activated
Security system present
(not activated)
Laboratory Used
Local
State
3
4
ATF
FBI
Check all that apply
5
Other
Federal
None
6
Private
NFIRS–11 Revision 01/01/04
A-58
NFIRS 5.0 Self-Study Program
A 92188
FDID
AZ
State
MM
DD
06
YYYY
25
0 4 4 4 9 9 9
2005
Incident Date
M2
Complete this section
if the person involved in
the ignition of the fire
was a child or Juvenile
under the age of 18
Station
Age or Date of Birth
Incident Number
1
2
3
16
Age (in years)
OR
4
5
Month
Day
Year
0
U
M1
Subject Number
Complete a separate Section M
form for each juvenile
0 0 1
M3
1
Gender
X Male
M5
2
Female
Subject Number
M7
Motivation/Risk Factors
1
2
3
4
5
6
7
8
9
0
U
N
X
Check only one of codes 1–3
and then all others (4–9)
that apply
M8
Mild curiosity about fire
Moderate curiosity about fire
Extreme curiosity about fire
History of trouble outside school
History of stealing or shoplifting
History of physically assaulting others
History of fireplay or firesetting
Transiency
Other
Unknown
Remarks (local use)
A-59
M6
White
Black, African American
American Indian, Alaska
Native
Asian
Native Hawaiian, Other
Pacific Islander
Other, multiracial
Undetermined
Ethnicity
1
0
Hispanic or Latino
Non Hispanic or Latino
Juvenile
Firesetter
Family Type
1
Single parent
2
Foster parent(s)
3
X Two-parent family
4
Extended family
N
No family unit
0
Other family type
U
Unknown
Disposition of Person Under 18
1
2
3
4
5
6
0
U
X Diagnosed (or suspected) ADD/ADHD
X
X
Change
Exposure
Race
M4
NFIRS–11
Delete
0
X
Handled within department
Released to parent/guardian
Referred to other authority
Referred to treatment/counseling program
Arrested, charged as adult
Referred to firesetter intervention program
Other
Unknown
| File Type | application/pdf |
| File Modified | 2008-02-12 |
| File Created | 2008-02-12 |