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pdfNFIRS 5.0 Self-Study Program
Civilian Fire Casualty
Module: NFIRS-4
Objectives
After completing the Civilian Fire Casualty Module the student will be
able to:
1. Describe when the Civilian Fire Casualty Module is to be used.
2. Demonstrate how to complete the Civilian Fire Casualty Module, given
the scenario of a hypothetical incident.
4-1
Table of Contents
Pretest #4 - Basic Civilian Fire Casualty Module. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4-3
Using the Civilian Fire Casualty Module . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4-4
Section A: FDID, State, Incident Number, Incident. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4-4
Section B: Injured Person. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4-4
Section C: Casualty Number. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4-4
Section D: Age or Date of Birth. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4-5
Section E: Race and Ethnicity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4-5
Section F: Affiliation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4-5
Section G: Date and Time of Injury. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4-6
Section H: Severity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4-6
Section I: Cause of Injury. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4-6
Section J: Human Factors Contributing to Injury . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4-7
Section K: Factors Contributing to Injury . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4-7
Section L: Activity When Injured . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4-7
Section M: Location at Time of Incident, General Location at Time of Injury,
Story at Start of Incident, Story When Injury Occurred, and
Specific Location at Time of Injury. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4-8
Section N: Primary Apparent Symptom. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4-9
Section O: Primary Area of Body Injured. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4-9
Section P: Disposition. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4-10
SUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4-10
EXAMPLE: Burn Victim. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4-11
EXERCISE SCENARIO 4-1: Market Street Fire. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4-13
EXERCISE SCENARIO 4-2: Cary Street Fire. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4-16
Civilian Fire Casualty Test. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4-22
NFIRS 5.0 Self-Study Program
Pretest #4 - Basic Civilian Fire Casualty Module
1. A civilian fire casualty is a nonfire service person who is injured or killed as a result of a fire.
(a) True.
(b) False.
2. The Civilian Fire Casualty Module can be used for civilian injuries resulting from an automobile
accident with no associated fire.
(a) True.
(b) False.
3. The Civilian Fire Casualty Module is not a required NFIRS Module.
(a) True.
(b) False.
4. The Civilian Fire Casualty Module can be used to report exposures to hazardous substances.
(a) True.
(b) False.
5. The Civilian Fire Casualty Module is completed for each civilian casualty reported in H1 of the
Basic Module.
(a) True.
(b) False.
4-3
NFIRS 5.0 Self-Study Program
Using the Civilian Fire Casualty Module
T
he Civilian Fire Casualty Module is used to record any civilian (nonfire service) casualty associated with a fire-related incident. When you enter information on Block H1 of the Basic Module,
the completion of this Module is required.
NOTE: A casualty is a person who dies or is physically injured as the direct result of a fire-related incident. In this circumstance
the term civilian includes, but is not limited to, private citizens, emergency medical responders (not part of the fire department),
utility workers, and police. Deaths also include people who die within 1 year of the incident because of injuries sustained from
the incident. In this case, it is important to submit a change to the Civilian Fire Casualty Module for that incident.
Section A: FDID, State, Incident Number, Incident
MM
A
DD
YYYY
Delete
FDID
State
Incident Date
Incident Number
Station
Exposure
Change
NFIRS–4
Civilian Fire
Casualty
Casualty
Injured Person
B information
C from
The
contained in Section A of the Civilian Gender
FireMale
Casualty
Module is drawn
Section
Number
1
2
Female
A of the Basic Module. Use the data in the Basic Module to help you supply the requested informaFirst Name
MI
Last
Name
tion.
If you are using an automated
system
the data need to be entered onlySuffix
once, thenCasualty
theyNumber
will be
transferred automatically into other
modules that use the data.
Race
D
Age or Date of Birth
A Months (for infants)
Age
FDID
E1
1
2
3
4
State
5
White
Black, African American
MM
DD
YYYY
Am. Indian, Alaska Native
Asian
Incident Date
Native Hawaiian, Other
Pacific Islander
Month
B
Other, multiracial
Undetermined
0
Injured Person U
Day
Year
First Name
E2
Affiliation
1
2
3
Station
0
Civilian
EMS, not fire department
Police
Incident Number
Other
H
Section B: Injured Person
OR
Date of Birth
F
Ethnicity
1
0
1
Exposure 2
3
Midnight is 0000.
of Injury
4
G Date and TimeGender
5
Date of Injury
Time of Injury
1
Male 2
Female U
Hispanic or Latino
Month
Last Name
Non HispanicMIor Latino
Day
Year
Hour
Severity
NFIRS–4
Delete
Minor
Civilian Fire
Moderate
Casualty
Change
Severe
Life threatening
Casualty
Death C
Number
Undetermined
Minute
Suffix
Casualty Number
E1 andRace
Section
B ofisInjury
used to enter the first
name,
middle initial,
and KanyFactors
suffixContributing
(i.e., Jr., Sr., and
III)
Affiliation
Factors
None
None
I Cause
JlastHuman
1
White
D Age or Date of Birth
F
H Severity
Contributing to Injury 1
to
Injury
Civilian
for
casualty.
2
Black, African American
Exposed
to fire products including flame
1 the
heat, smoke, and gas
Months (for infants)
3
Am. Indian, Alaska Native
2
Enter up
to three
contributing factors
EMS, not
fire
department
Minor
3
Police
4
Asian
Exposed
to toxic fumes
other thanwhether
smoke
2
Boxes
areAgeavailable
to indicate
the
casualty
is male or
female.
You are required to 12fill inModerate
the
Check
all applicable
boxes
0
Other
Native Hawaiian, Other
5
3
Jumped in escape attempt
Contributing factor (1)
Severe
3
1
Asleep
Pacific
Islander
gender
field.
Midnight is 0000.
Fell, slipped, or OR
tripped
4
Life threatening
4
2 multiracial
Unconscious
Other,
G Date and Time of Injury
0
5
Caught or trapped
Death
5
3
Possibly
impaired
by
alcohol
U
Date
of
Birth
Undetermined
Date
of
Injury
Time
of
Injury
Structural collapse
6
Contributing factor (2)
Undetermined
U
4
Possibly
impaired
by
other
drug
7
Struck by or contact with object
Ethnicity
DD
YYYY
PossiblyNFIRS–4
mentally disabled
E2 1 5 Hispanic
Delete
Overexertion
or
strain
8
or Latino
Civilian
Fire
Month
Day
Year
Month
Day
Year
Hour
Minute
6
Physically
disabled
MultipleIncident
causes
9 Station
Number
ent Date
Exposure
Hispanic or
Latino
0 7 NonChange
Casualty
Contributing factor (3)
Physically
restrained
Other
0
8
Unattended person
U
Undetermined
of Injury
Human Factors
Contributing
None
Casualty
Gender
None
I Cause
K Factors
C J Number
Contributing to Injury
to Injury
1 Injured
2 products
Time of Incident
Male
FemaleLocation
1 When
Exposed
to fire
includingatflame
Activity
Story
at
Start
of
Incident
M1 1 In area of origin and not involved
L
M3 Complete ONLY if injury
Enter up to three contributing factors
heat, smoke, and gas
occurred INSIDE
2
Not
in
area
of
origin
and
not
involved
Exposed to toxic fumes other
than smoke Check allNumber
2
applicable boxes
MI
Last Name
Story at start of incident
3 SuffixNot in area of Casualty
Below grade
origin,
but
involved
1
Escaping
3
Jumped in escape attempt
Contributing factor (1)
4
In area of origin1and involved
Asleep
2
Rescue
4 attempt
Fell, slipped, or tripped 0
Other location 2
Race
Unconscious
3
1
Fire control
M4 Story Where Injury Occurred
5 Affiliation
Caught or trapped
U
UndeterminedSeverity
3
Possibly
impaired
by alcohol
4
White
F 6 to fire
Return
before
control
H
Structural
collapse
Story where injury occurred,
if
1 fire
Civilian
Contributing
factor (2)
Below grade
4 TimePossibly
impaired by
other
5
Black, African American
Return
after
control
different
from drug
M3
General
Location
at
of
Injury
7 to
Struck
by
or
contact
with
object
M2
2
EMS, not fire department
5
Possibly
mentally
disabled
Am. Indian, Alaska Native
6
Sleeping
8 3 Overexertion
or
strain
Minor
1
Police
6
Physically
Asian
7
Unable
act
Skipdisabled
to
9 to
Multiple
1
In area of fire
at Time of Injury
Moderate
2 origin
Section
N
0 act
Othercauses
Contributing factor (3)
7
Physically
restrained
Native Hawaiian, Other
M5 Specific Location
8
Irrational
0
Other
2
In
building,
but
not
in
area
Severe
3
Pacific Islander
Complete ONLY if casualty NOT in area of origin
8
Unattended
person
0
Midnight is 0000.
OtherU
Skip
to
Outside, but4not inLife
area
and Time of Injury3
threatening
Block M5
Other, multiracial U
G DateUndetermined
Undetermined
U
Undetermined
Death
5
Undetermined
Date of Injury
Time of Injury
Specific location at time of injury
Undetermined
U
at Time of Incident
Story at Start of Incident
Ethnicity
M1 Location
L Activity When Injured
M3 Complete
1
In area of origin and not involved
2
ONLY if injury occurred INSIDE
Primary
Apparent
1
Hispanic or Latino
Month
Day
YearSymptom Hour
Minute
2
NotArea
in area
originInjured
and not involved Disposition
Primary
ofofBody
N
O
P
Story at start of incident
3
Below grade
Non Hispanic or Latino
Not in area of origin, but involved
0
1
Escaping
4
In area of origin and involved
01
only,attempt
asphyxiation
2Smoke
Rescue
Section C: Casualty Number
Each casualty is given a number. The numbers are assigned consecutively starting with one (001) and
continuing, based on how many civilians are injured or killed.
4-4
MM
A
FDID
State
DD
YYYY
Incident Date
B
Incident Number
Station
NFIRS 5.0 Self-Study Program
Gender
1
Male
Injured Person
Section D: Age or Date of Birth
First Name
D
MI
Age or Date of Birth
Months (for infants)
Age
E1
Date of Birth
Month
Day
Year
Female
Suffi
Race
White
Black, African American
Am. Indian, Alaska Native
Asian
Native Hawaiian, Other
Pacific Islander
0
U
Other, multiracial
Undetermined
E2
2
Last Name
1
2
3
4
5
OR
Exposure
F
Affiliation
G
Date and Time of Injury
1
2
3
0
Civilian
EMS, not fire department
Police
Other
Date of Injury
Midnight is
Time of Injury
Ethnicity
1
0
Hispanic or Latino
Non Hispanic or Latino
Month
Day
Year
Hour
Minute
Human Factors
of Injury
Enter either the age or the date of birthI of Cause
the casualty
in Section D. Do not Jenter
both. The number None K Factor
Contributing to Injury
to Inju
Exposed to
fire
products
including
flame
1 provided
associated with the age is assumed to beMM
in
years
unless
the
months
box
is
marked.
The
age
DD
YYYY
NFIRS–4
Enter up to three c
heat, smoke, and gas
Delete
A
Civilian Fire
should be recordedFDID
in months only
forIncident
infants
whotoare
than
1 than
year
old
at the timeExposure
of
Exposed
toxicless
fumes
other
smoke
2
boxesinjury.
Incident
Number Check all applicable
Date
Station
State
Casualty
B
A
Injured Person
FDID
Section E: Race and Ethnicity
State
First Name
B
D
3
Jumped in escape attempt
1
Fell, slipped, or tripped
4
2
5
Caught
or
trapped
MM
DD
YYYY
Gender 3
Structural collapse
6
1
Male4
7 Date
Struck by or contact Station
with objectIncident Number
Incident
5
Overexertion or strain
8
6
MI causes
Last Name
Multiple
9
7
Other
0
Gender 8
Undetermined
U
Race
E1
1
Male
Affiliation
Injured Person
Age or Date of Birth
1
2
3
4
15 1
21
320
43U
54
65 2
F
White
Change
Contributing factor (
Asleep
Unconscious
Casualty
NFIRS–4
Possibly impaired by alcohol
C Number
Delete
Contributing
Civilian
Firefactor (
2 Possibly
Femaleimpaired by other drug
Exposure
Casualty
Change
Possibly
mentally disabled
Physically disabled
Casualty Number
Suffix
Contributing factor (
Physically restrained
Casualty
Unattended person
C Number
2
Female
Severity
H
1 Location
Civilian
at Time of Incident
Story at Start
Casualty
Number
Suffix
M3 Complete
notof
fire
department
1 EMS,
In area
origin
and not involved
Am. Indian, Alaska Native
ONLY if injur
Months (for infants)
Minor
1
3
Police
2
Not in area of origin and not involved
Asian
Age
Story
at
start
of
incident
Moderate
2
RaceHawaiian, Other
Not in area of origin, but involved
0 3 Other
E Escaping
Native
Affiliation
Severity
Date of Birth
4
Severe
In area of origin and involved
3
Rescue
attempt
Pacific Islander
White
D Age orOR
F
Midnight is 0000. H
Other of
location
Time
Injury
Life threatening
1 0and
Civilian
4
Fire
control
Black,
African
American
Other,
multiracial
G Date
M
4 Story Where I
U
Undetermined
Death
2
EMS,
not
fire
department
5
Return
to fire
before
control
Am.
Indian,
Alaska
Native
Date of Birth
Undetermined
Date of Injury
Time of Injury
Story where injury occurred
Months (for infants)
Minor
1
3
Police
Undetermined
Return
to fire after control
Asian
different from M3
Location at Time of Injury U
Ethnicity
Age
M02 General
Moderate
2
Other
E 1Sleeping
Native Hawaiian, Other
Hispanic
or
Latino
Month
Day
Year
Severe
3
Month
Day
Year
Hour
Minute
1
Pacific Islander
7
Unable
to act
Midnight is 0000.Skip to
OR
1
area
of fire
origin
Specific Loca
Non Hispanic or Latino
0
and
Time
of Injury
Life
Section
4N M
5 threatening
80
Irrational
act
Other, multiracial
G 2Date In
In building, but not in area
Death
5
Complete
ONLY if cas
0U
Date of Birth
Other
Undetermined
Date of Injury
Time of Injury
Skip to
3
Outside, but not in area
Undetermined
Block U
M5
U
Undetermined
Human
Factors
Factors
Contributing
Cause
of
Injury
None
Ethnicity
None
I
K to Injury
U
Undetermined
E2 1 Hispanic orJ Latino
Specific location at tim
Contributing to Injury
Month Exposed
Day
Month
Day
Year
Hour
Minute
1
to Year
fire products including
flame
Enter up to three contributing factors
Non Hispanic or Latino
0
heat, smoke, and gas
Primary Apparent Symptom
Disposition
Primary
Area
of Body Injured P
Exposed to toxic fumes other
than
smoke
2
N
O
Check all applicable boxes
Jumped
in
escape attempt
3
Human
Factors
Factors
Contributing
Cause
of
Injury
None
Contributing
factor
(1)
01
SmokeJ
only, asphyxiation
None
I4 Fell, slipped, or tripped
1
Asleep
2
K to Injury
Transported
t
Contributing
to Injury
11
Burns and
inhalation
2 smoke
Unconscious
1
Head
15DD Exposed
to fire products including
flame
Caught
MM
YYYY or trapped
NFIRS–4 Enter up to three contributing factors
12
Burns
only
3
Possibly
impaired
by
alcohol
Delete
2
Neck and shoulder
heat,
smoke,
and gas
A
6
Structural
collapse
Civilian
Fire
Contributing factor (2)
21
Cut, laceration
4
Possibly impaired by other
drug
Remarks
3
Thorax
Exposed
fumes
other
than
Incident
Numbersmoke
Struck bytoortoxic
contact
with
object
7
Incident Date2
Check Exposure
all applicable boxes
FDID
Station
State
Casualty
Change
33
Strain or
sprain
5
Possibly
mentally
disabled
4
Abdomen
Jumped
in
escape
attempt
38
Overexertion or strain
Contributing
factor
(1)
Asleep
96
Shock 16
Physically disabled
5
Spine
49
Fell,
slipped,
or tripped
Multiple
causes
27
Unconscious
98
Pain only
factor (3)
Physically restrained 6Casualty
UpperContributing
extremities
Caught
or
trapped
5
0
Other
Gender
38
Possibly
impairedC
by alcohol
B Injured Person
Unattended
7Number
Lower extremities
Look up a code only if the symptom
is NOT
found above person
6U
Structural
collapse
Undetermined
Contributing factor (2)
1
Male 2 4 Female
Possibly impaired by other
drug
8
Internal
Struck by or contact with object
7
5
Possibly
mentally
disabled
9
Multiple
body parts
8
Overexertion or strain
Primary apparent
symptom 6at Time
of Incident
Physically
When
Injured
Story at Start of Incident
First Name
Last Name
Suffix disabled Casualty Number
M1 Location
Multiple
causes
9L MI Activity
M
3
1
In area
and not
involved
Contributing
(3) occurred INSIDE
Complete
ONLYfactor
if injury
7 of origin
Physically
restrained
0
Other
2
Not8in areaUnattended
of origin andperson
not involved
Race
Story
at
start
of
incident
U
Undetermined
Below grade
Not in area of origin, but involved
E1 1 Escaping
Affiliation 3
Severity
4
In area of origin and involved
1
White
D Age or Date of Birth
F
2
Rescue attempt
H
0
1
Civilian
Other location
Story at
Where
Occurred
2
Black,
African
American
3
Fire control
Location
at Time of Incident
M34 Story
Activity
When Injured
StartInjury
of Incident
Undetermined
MEMS,
1 Unot fire
L Indian,
M
2
department
3
Am.
Alaska
Native
4
Return
to fire
before control
1
In area of origin and not involved
Complete
ONLY
if
injury
occurred
INSIDE
Months (for infants)
Minor Story where injury occurred, if
1involved
Police
Below grade
2General
4
Asian
Not Location
in area of origin
andof
not
5
Return to fire after control3
different from M3
at Time
Injury
Age
Moderate
2
M
2
Story
at
start
of
incident
0
Other
3
Below grade
Not in area of origin, but involved
16
Native
Hawaiian, Other
Escaping
5
Sleeping
Severe
3
4
In area of origin
and involved
Pacific
Islanderto
27
Rescue
attempt
Midnight is 0000.
Unable
act
Skip to
OR
1 Time
0In area
ofOther
Injury
Life
of fire
origin
Specific
Location
Time of Injury
4 Section
location
N threatening
Where
Injury at
Occurred
38
Fire
control
Other,
multiracial
G Date and
0
M5 Story
Irrational
act
UIn building,
Undetermined
2
Death 4 Complete ONLY if casualty NOT in area of origin
but
not
in
area
5
U
40
Date of Birth
Undetermined
Return
to
fire
before
control
Date of Injury
Time of Injury
Other
Skip to
Story where injury occurred, if
3
Undetermined
Outside, but not in area
U Block
Below grade
M5
5U
Return
to fire after control
different from M3
Undetermined
Ethnicity
General Location at Time of Injury
M
2
U
Undetermined
E2 1 6 Hispanic
Sleeping
Specific
location
at
time
of
injury
or Latino
Month
Day
Year
Month
Day
Year
Hour
Minute
7
Unable to act
Skip to
1
Non Hispanic or Latino
0
In area of fire origin
Section N
M5 Specific Location at Time of Injury
8
Irrational
act
Primary Apparent Symptom 2
In building,Primary
but notArea
in area
Disposition
of
Body
Injured
ONLY if casualty NOT in area of origin
0N Other
O
P Complete
Skip to
3
Outside, but not in area
Block M5
Human
Factors
Factors
Contributing
U 01Undetermined
None
None
I Cause of Injury
J
K to Injury
Smoke only, asphyxiation
U
Undetermined
Transported to emergency care facility
to Injury
Specific location at time of injury
11
BurnsContributing
and smoke inhalation
1
Exposed to fire products including flame
1
Head
Enter up to three contributing factors
12
Burns only
heat, smoke, and gas
2
Neck and shoulder
First Name
L
Black, African
American
Activity
When
Injured
MI
Last Name
M21
Block E contains six boxes. Mark one box to record the race of the casualty, if known.
Block E allows you to identify the ethnicity of the casualty. Ethnicity is an ethnic classification or
affiliation. Currently, Hispanic is the only U.S. Census Bureau classification. Hispanic is not considered a race, because a person can be black and Hispanic, white and Hispanic, etc.
Section F: Affiliation
Section F is used to mark the casualty’s affiliation - civilian, EMS (not fire department), police, or other.
4-5
MM
Gender
1
Male
Injured Person
B
First Name
MI
Age or Date of Birth
D
Months (for infants)
Age
E1
Month
I
Year
E2
Casualty Number
Suffix
Affiliation
F
1
2
3
0
Severity
H
Civilian
EMS, not fire department
Police
Other
Section G: Date and Time of 1Injury
Minor
Midnight is 0000.
Date and Time of Injury
G
Other, multiracial
Undetermined
0
U
Day
Casualty
Number
NFIRS 5.0 Self-Study Program
White
Black, African American
Am. Indian, Alaska Native
Asian
Native Hawaiian, Other
Pacific Islander
OR
Date of Birth
C
Female
Last Name
Race
1
2
3
4
5
2
Date of Injury
Time of Injury
Ethnicity
1
0
Hispanic or Latino
Non Hispanic or Latino
Month
Day
Year
Hour
Moderate
Severe
Life threatening
Death
Undetermined
2
3
4
5
U
Minute
Factors
Factors Contributing
None
NFIRS–4
None
J Human
K appropriate
Record the month, day, year,
and time
of theDelete
injury
in the
spaces. Time
- hours and minContributing to Injury
Civilian Fire to Injury
Exposed to fire
products
including
flame on theExposure
Incident Number
Station
utes
is
entered
based
24-hour
clock
where
midnight
is
0000.
Casualty
Change
Enter up to three contributing factors
heat, smoke, and gas
DD
YYYY
Cause of
Injury
ident1
Date
Exposed to toxic fumes other than smoke Check all applicable boxes
2
3
Jumped in escape attempt
Casualty
Gender
1
Asleep
C NumberContributing factor (1)
4
Fell, slipped, or tripped
1
Male 2
Female
Unconscious
5
Caught or trapped
3
Possibly impaired by alcohol
6
Structural collapse
Contributing factor (2)
4
Possibly Suffix
impaired by other
drug
Casualty
Number
MI
Last
7
Struck
byName
or contact with object
MM
DD
YYYY
5
Possibly mentally disabled
Overexertion or strain
8
D
A disabled
6
Physically
Multiple causes
E1 9 Race
Incident Number
Incident Datefactor (3)
FDID
Station
Exposure
State
Affiliation
Contributing
7
Physically
restrained
C
Severity
Other
1 0 White
F
H
8
Unattended person
1
Civilian
Undetermined
U
2
Black, African American
2
EMS, not fire department
3
Am. Indian, Alaska Native
Gender
Injured Person
Minor
1
3
Police
4
Asian
Location at Time of B
Incident
Activity
When
Injured
Story
at
Start
of
Incident
1
Male 2
Female
Moderate
2
M3
0 M1 Other
5 L Native Hawaiian, Other
1
In area of origin and not involved
Severe Complete ONLY if injury occurred INSIDE
3
Pacific Islander
2
Not in area of origin
and
not
involved
Midnight is 0000.
Life threatening
4
Story at start of incident
Below grade
First Name
MI
Last Name
Suffix
area of origin,
but involved
Escaping
multiracial
G Date and3 TimeNotof inInjury
0 1 Other,
Death
4
In
area
of
origin
and involved 5
U 2 Undetermined
Rescue attempt
Date of Injury
Time of Injury
0
Other location
Undetermined
U
Injury Occurred
3 Ethnicity
Fire control
M4 Story
E1WhereRace
U
Undetermined
Affiliation
E24 1 Return
Age
or
Date
of
Birth
to fire before control
1
White
D
F
Hispanic or Latino
H
Story
where
injury
occurred,
if
Month
Day
Year
Hour
Minute
Below
grade
5
1
Civilian
Return to fire after control
different from
General Location at Time of Injury
2 M3 Black, African American
Non Hispanic or Latino
0
M
2
6
2
EMS, not fire department
Sleeping
3
Am. Indian, Alaska Native
Months (for infants)
1
7
3
Police
Unable to act
Skip to
4
Asian
1
In area of fire originAge
Specific
Location
at
Time
of
Injury
Section N
2
8
Factors Contributing M5
0
Other
Irrational J
act Human Factors2
None
Native Hawaiian, Other
5
None
In building, butKnot in area
Complete ONLY if casualty NOT in area of origin
3
0
Contributing to3Injury
to Injury
Other
Pacific Islander
Skip to
Midnight
is
0000.
OR
Outside, but not in area
ncluding
flame
Block M5
Date and Time of Injury
4
U
Undetermined
Enter up to three contributing factors
Other,
multiracial
G
0
U
Undetermined
5
Specific
at time of injury
U location
Date of Birth
Undetermined
Date of Injury
Time of Injury
her than smoke Check all applicable boxes
U
Ethnicity
t
Contributing factor (1)
E
2
1
Asleep
Primary Apparent
Symptom
Disposition
1
Hispanic or Latino
Month of Body
Day Injured
Year
Month
Day
Year
Hour
Minute
N
O Primary Area
P
2
Unconscious
Non Hispanic or Latino
0
01
Smoke
asphyxiation
3 only,
Possibly
impaired by alcohol
Transported to emergency care facility
Contributing factor (2)
Burns
smoke inhalation
4 andPossibly
impaired by other1drug Head
object 11
Cause of Injury
Factors
Contrib
12
Burns
None
5 only
Possibly mentally disabled2
Neck and
I shoulder
J Human
K Factors
Local option
Contributing to Injury
to Injury
21
Cut,6laceration
Physically disabled
Remarks
3
Thorax1
Exposed to fire products
including flame
Contributing factor (3)
33
Strain
7 or sprain
Physically restrained
Enter up to three contributing fac
4
Abdomen
heat, smoke, and gas
96
Shock
8
Unattended person
5
Spine 2
Exposed to toxic fumes other than smoke Check all applicable boxes
98
Pain only
6
Upper 3
extremities
Jumped in escape attempt
Contributing factor (1)
1
Asleep
7
Lower
extremities
Look up a code only if the symptom is NOT found above
4
Fell,
Location at Time of Incident
Story
at
Start
of slipped,
Incident or tripped
2
Unconscious
M1 1 In area of origin and not involved
8M3 Internal5
Caught
or
trapped
Complete ONLY if injury occurred INSIDE
3
Possibly impaired by alcohol
9
Multiple
parts collapse
2
Not in area of origin and not involved
6 body
Structural
Primary apparent symptom
Revision 01/01/04
4 NFIRS–4
Possibly
impaired by other drug Contributing factor (2)
Story
at start of incident
3
Below
gradeobject
Not in area of origin, but involved
7
Struck by or contact
with
5
Possibly mentally disabled
4
In area of origin and involved
8
Overexertion or strain
0
Other location
6
Physically disabled
Injury Occurred
9
Multiple
causes
M4 Story Where
U
Undetermined
Contributing factor (3)
7
Physically restrained
ol
0
Other
Story where injury occurred, if
8
Unattended person
Below grade
Undetermined
different from M3U
General
Location
at
Time
of
Injury
M2
Section H: Severity
Enter the severity of the injury in Section H. Check one of the five boxes shown: minor, moderate,
severe, life threatening, and death. Severity is a required field.
Section I: Cause of Injury
1
2
3
U
om
iation
halation
above
Skip to
at Time of Incident
Specific
Time
of InjuryYou must
Activity
Injured
Story at Start of Incide
Section N
M5 the
M1 Location
Mark one box to
record
main
causeatWhen
of
injury.
choose
from the eleven possibiliL Location
M3 Complete
1
In area of origin and not involved
ONLY if injury occurred INS
Complete ONLY if casualty NOT in area of origin
Skip to
2
Not in area of origin and not involved
ties provided. Block
M
Story at start of incident
3
Not in area of origin, but involved
1
In area of fire origin
In building, but not in area
Outside, but not in area
Undetermined
O
1
2
3
4
5
6
7
8
9
5
Primary Area of Body Injured
Head
Neck and shoulder
Thorax
Abdomen
Spine
Upper extremities
Lower extremities
Internal
Multiple body parts
Escaping
4
0
U
Specific location
time of injuryattempt
2 atRescue
3
Fire control
4
Return to fire before control
Disposition
P
5
Return to fire after control
6
Sleeping
Transported to emergency care facility
7
Unable to act
8
Irrational act
Local option
Other
Remarks 0
U
Undetermined
In area of origin and involved
Other location
Undetermined
M4
M2
General Location at Time of Injury
1
2
3
U
In area of fire origin
In building, but not in area
Outside, but not in area
Undetermined
Skip to
Section N
Story Where Injury Oc
Story where injury occurred, if
different from M3
M5
Specific Location at T
Complete ONLY if casualty NOT in a
Skip to
Block M5
Specific location at time of injury
4-6
Primary Apparent Symptom
N
01
11
12
Smoke only, asphyxiation
Revision 01/01/04
BurnsNFIRS–4
and smoke
inhalation
Burns only
O
Primary Area of Body Injured
P
Disposition
Transported to emerg
1
2
Head
Neck and shoulder
D
Months (for infants)
Age
1
2
3
4
5
White
Black, African American
Am. Indian, Alaska Native
Asian
Native Hawaiian, Other
Pacific Islander
0
U
Other, multiracial
Undetermined
OR
Date of Birth
F
1
2
3
0
Civilian
EMS, not fire department
Police
Other
NFIRS 5.0 Self-Study
Program
G Date and Time of Injury
Date of Injury
Midnight is 0000.
Time of Injury
Day
1
2
3
4
5
U
Minor
Moderate
Severe
Life threatening
Death
Undetermined
SectionE2J: Human Factors Contributing to Injury
Ethnicity
Month
H
1
0
Year
Hispanic or Latino
Non Hispanic or Latino
Month
Day
Year
Hour
Minute
Factors
Contributing
None
None
J Human
K Factors
YYYY
NFIRS–4
Contributing to
Injury
to Injury
Delete
Civilian Fire
Exposed to fire products including flame
Enter up to three contributing factors
Incident Date
Station
Exposure
te
Casualty
heat, smoke,
and gas Incident Number
Change
Exposed to toxic fumes other than smoke Check all applicable boxes
2
3
Jumped in escape attempt
Contributing factor (1)
1
Asleep
Casualty
Fell, slipped, or tripped Gender
4
2
Unconscious C
Number
1
5
Caught or trapped
Male 2
Female
3
Possibly impaired by alcohol
Structural collapse
6
4
Possibly impaired by other drug Contributing factor (2)
7MI
Struck
by
or
contact
with
object
Number
Last Name
Suffix
5
Possibly
mentallyCasualty
disabled
Overexertion or strain
8
6
Physically disabled
Multiple causes
9
Race
Contributing factor (3)
7
Physically restrained
E1
Other
0
Affiliation
Severity
rth
8
UnattendedHperson
1
White
MM
DD
YYYY
U
Undetermined F
1
Civilian
A
2
Black, African American
2
EMS,
not
fire
department
3
Am. Indian, Alaska Native
Incident Number
Incident Date
FDID
Station
Exposure
State
ants)
Location at Time of Incident
Minor
1
Police
Activity When Injured 3
4
AsianL
M
1
M
3 Story at Start of Incident
1
I
n
area
of
origin
and
not
involved
Moderate
2
0
Other
Complete ONLY if injury occurred INSIDE
Native Hawaiian, Other
5
2
Not in area of origin and3not involved
Severe
Pacific Islander
Midnight
is 0000. but
Gender
Story at start of incident
Injured
Person
3
Below grade
Not
in
area
of
origin,
involved
1
Escaping
Life threatening
4
B
Other,
G Date and Time 4of Injury
0
In area of origin and involved
1
2 multiracial
Male 2
Female
Rescue attempt
Death
5
U
0
Undetermined
Date of Injury
Time
of Injury
Other
location
Story Where Injury Occurred
3
Fire control
Undetermined
M
4
U
U
Undetermined
Ethnicity
4
Return to fire before control
First Name
MI occurred,
Last Name
Suffix
E2 1 Hispanic
Story where injury
if
Below grade
5
or Latino
Return
to fire after
control
Month
Day
Year General Location
Hour
Minute
different from M3
at Time of Injury
M2
6 Hispanic
Non
or Latino
0
Sleeping
Race
E1
7
Unable to act
Skip to
Affiliation
Age or Date of Birth
1
In area of fire
origin
Specific
Location at Time F
of Injury
Section N
1
White
D
M5
8
Irrational act
2
1
Civilian
In
building,
but
not
in
area
Human
Factors
Factors
Contributing
None
2
Black,
African
American
None Complete ONLY if casualty NOT in area of origin
J Contributing to Injury 3 Outside,Kbut not
0
Other
Skip to
2
EMS, not fire department
in area
to Injury
3
Am. Indian, Alaska Native
Block M5
U
Undetermined
roducts including flame
Months (for infants)
3
Police
U
Undetermined
4
Asian
Enter up to three contributing factors
Age
Specific location at time of injury
gas
0
Other
Native Hawaiian, Other
5
fumes other than smoke Check all applicable boxes
Pacific Islander
Midnight is 00
OR
e attempt
Primary Apparent Symptom
Date and Time of Injury
Contributing
factorArea
(1)
Disposition
Primary
of Body Injured P0
Other, multiracial
G
1
Asleep
N
O
ripped
U
Date of Birth
Undetermined
Date of Injury
Time of Injury
2
Unconscious
d
01
Smoke only, asphyxiation
Transported
to emergency care facility
3
Possibly impaired by alcohol
Ethnicity
se
11
Burns and smoke inhalation
E2 1 Hispanic or Latino
Head
factor (2)
4
Possibly impaired by other drug 1Contributing
act with object
Month
Day
Year
Month
Day
Year
Hour
Minute
12
Burns only
2
Neck and
shoulder
5
Possibly
mentally
disabled
Non Hispanic
Latino
0
train
Localor
option
21
Cut, laceration
Remarks
3
Thorax
6
Physically disabled
33
Strain or sprain
4Contributing
Abdomen
factor (3)
7
Physically restrained
96
Shock
5
Spine
Factors
Cause of Injury
None
8
Unattended person
I
J Human
K Factors
98
Pain only
6
Upper extremities
Contributing to Injury
to Injury
Exposed
to fire products including flame
1 Lower
7
extremities
Look up a code only if the symptom is NOT found above
Enter up to three con
heat, smoke, and gas
at Time of Incident
8
Internal
ured
Story
at
Start of Incident
M1 Location
M3 Complete
Exposed
toxic fumes other than smoke Check all applicable boxes
2ONLY
1
In area of origin and not involved
9
Multiple
bodytoINSIDE
parts
if injury occurred
apparent symptom
3
Jumped in escape attempt
2PrimaryNot
in area of origin and not involved
NFIRS–4 Revision 01/01/04
Contributing factor (1)
1
Asleep
Story at start of
3
Below grade
Not in area of origin, but involved
Fell, slipped, or tripped
4 incident
2
Unconscious
4
In area of origin and involved
5
Caught or trapped
3
Possibly impaired by alcohol
0
Other location
Injury Occurred
Structural
collapse
M4 Story6Where
U
Undetermined
4
Possibly impaired by other drug Contributing factor (2)
7
Struck by or contact with object
ore control
Story where injury occurred, if
5
Possibly mentally disabled
Below
grade
Overexertion or strain
r control
different from 8
M3
6
Physically disabled
M2 General Location at Time of Injury
9
Multiple causes
Contributing factor (3)
7
Physically restrained
0
Other
Skip to
1
In area of fire origin
Location at Time of Injury
8
Unattended person
Section N
M
5 Specific
Undetermined
U
2
In building, but not in area
Complete ONLY if casualty NOT in area of origin
Skip to
3
Outside, but not in area
Block M5
U
Undetermined
M1 Location at Time of Incident
L Activity When Injured
M3 Story at Start o
MM
DD
I
Cause of Injury
1
You may mark as many of the items shown in Section J as you think apply to the casualty. If no human
factors contributed to the injury, check the box marked None.
Section K: Factors Contributing to Injury
If there are factors other than human ones that contributed to the injury, record them in Section K.
If there were no other factors, check the box marked None.
Codes found in the NFIRS Complete Reference Guide (CRG) can be used to identify up to three factors.
Section L: Activity When Injured
Specific location at time of injury
nt Symptom
y, asphyxiation
smoke inhalation
ion
rain
is NOT found above
O
1
2
3
4
5
6
7
8
9
Primary Area of Body Injured
Head
Neck and shoulder
Thorax
Abdomen
Spine
Upper extremities
Lower extremities
Internal
Multiple body parts
1
Escaping
Disposition
2
Rescue attempt
3
Fire control
Transported
to emergency care facility
4
Return to fire before control
5
Return to fire after control
M2
Sleeping
Local option
Remarks 6
7
Unable to act
1
8
Irrational act
2
0
Other
3
U
Undetermined
U
P
1
2
3
4
0
U
In area of origin and not involved
Not in area of origin and not involved
Not in area of origin, but involved
In area of origin and involved
Other location
Undetermined
Complete ONLY if injury o
Story at start of incident
M4
General Location at Time of Injury
In area of fire origin
In building, but not in area
Outside, but not in area
Undetermined
Skip to
Section N
Story Where In
Story where injury occurred, if
different from M3
M5
Specific Locat
Complete ONLY if casua
Skip to
Block M5
Specific location at time
Record what the casualty was doing at the time
of the
injurySymptom
by checking one of Primary
the boxes
in Section L.
Primary
Apparent
Area of Body Injured
N
NFIRS–4
01
11
12
21
33
96
98
Revision 01/01/04
Smoke only, asphyxiation
Burns and smoke inhalation
Burns only
Cut, laceration
Strain or sprain
Shock
Pain only
4-7
O
P
Disposition
Transported to
1
2
3
4
5
Head
Neck and shoulder
Thorax
Abdomen
Spine
Remarks
Lo
First Name
D
MI
E1
Age or Date of Birth
Months (for infants)
Casualty Number
Suffix
Race
Affiliation
F
1
NFIRS 5.0 Self-Study Program
2
1
2
3
4
5
Age
Last Name
White
Black, African American
Am. Indian, Alaska Native
Asian
Native Hawaiian, Other
Pacific Islander
3
0
Civilian
EMS, not fire department
Police
Other
Severity
H
Minor
Moderate
Severe
Life threatening
Death
Undetermined
1
2
3
4
5
U
is 0000. who develop
OR
How people respond
to an emergency provides important
information to theMidnight
people
Other, multiracial
G Date and Time of Injury
0
safety codes
and standards. U Undetermined
Date of Birth
Date of Injury
Time of Injury
Ethnicity
2
Public Month
education
programs
areEdesigned
to orprevent
injuries.
However,
they Hour
also Minute
teach people how to
1
Hispanic
Latino
Day
Year
Month
Day
Year
Non Hispanic or Latino
0
react in the safest manner possible during an emergency. Recording information about the activity
associated Cause
withofanInjury
injury can help determine the
focus of a new public
education
program, or help
Human Factors
Factors Contributing
None
None
I
J
K
determine
if an existing public education program
is having
the desired result.to Injury
Contributing
to Injury
1
Exposed to fire products including flame
MM
State
DD
Incident Date
2
3
4
5
6
7
8
YYYY
9
0
U
heat, smoke, and gas
Exposed to toxic fumes other than smoke Check all applicable boxes
Jumped in escape attempt
1
Asleep
Fell, slipped, or tripped
2
Unconscious
Caught or trapped
3
Possibly impaired by alcohol
Structural collapse
4
Possibly impaired by other drug
Struck by or contact with object
5
Possibly mentally disabled
Overexertion or strain
6
Physically disabled
NFIRS–4
Multiple causes
Delete
7
Physically
restrained
Civilian Fire
Other
Incident Number
Unattended
person
Station
Exposure 8
Casualty
Change
Undetermined
Activity When Injured
Gender
L
1
(for infants)
E1
1
2
3
4
5
E2
M1
2
Male
Location at Time of Incident Casualty
1
In area of origin andC
not involved
Number
Female
2
M3
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
Story at start of incident
3
Below grade
Not in area of origin, but involved
1
Escaping
4
In areaSuffix
of origin and involved
2 NameRescue attempt
Casualty Number
MI
Last
0
Other location
3
Fire control
M4 Story Where Injury Occurred
U
Undetermined
Return to fire before control
Race 4
Story where injury occurred, if
Below grade
Affiliation
5
Return to fire after
control
different from M3
Time Severity
of Injury
White
F
M
2 General Location atH
6
Sleeping
1
Civilian
Black, African American
7
Unable to act 2
Skip to
EMS, not1 fire department
Am. Indian, Alaska Native
In area of fire origin
Section N
M5 Specific Location at Time of Injury
8
Irrational act
Minor
1
3
Police 2
Asian
In building, but not in area
Complete ONLY if casualty NOT in area of origin
0
Other
Moderate
2
Skip
to
0
Other 3
Native Hawaiian, Other
Outside, but not in area
Block M5
U
Undetermined
Severe
3
Pacific Islander
U
Undetermined
Midnight is 0000.
Life threatening
Specific location at time of injury
4
Other, multiracial
G Date and Time of Injury
Death
5
Undetermined
Date of Injury
Time of Injury
Undetermined
U
Primary Apparent Symptom
Ethnicity N
O Primary Area of Body Injured P Disposition
0
U
ear
Contributing factor (1)
Section M: Location at Time of Incident, General Location
at Time of Injury, Story at Start of Incident, Story When
Injury Occurred, and Specific Location at Time of Injury
on
of Birth
Enter up to three contributing factors
Use Section M to record information that identifies when and where the injury took place.
1
0
Hispanic or Latino
01
J21
ry
Monthonly,
Dayasphyxiation
Year
Smoke
Hour
Minute
Transported
to emergency
carefire
facility
Non Hispanic
Latino
1 Burns
Use
Block
to mark
one box
that describes
the location of the casualty
at the time
that the
11orM
and smoke
inhalation
1
Head
12
Burns
only
started.
2
Neck and shoulder
Local option
Cut,Factors
laceration
Human
None
K
Contributing
3Factors
Thorax
None Remarks
33 Contributing
Strain or sprain
Injury
4to general
Abdomen
location of the casualty at the time of the injury.
Mark
boxestoinInjury
M2 to indicate the
re products including
flame one96of the
Shock
5 to threeSpine
Enter up
contributing factors
and gas
98
Pain
only
Leave this block blank and skip to Section 6N if Upper
the location
is undetermined.
extremities
oxic fumes other than smoke
scape attempt
or tripped
pped
llapse
contact with object
or strain
ses
d
n Injured
Check all applicable boxes
Look up a code only if the symptom is NOT found above
d
Lower extremities
2
Unconscious
Primary apparent symptom
9
Multiple body parts
3
Possibly impaired by alcohol
If you mark
“Outside,
but not in area,” skip to M5.
4
Possibly impaired by other drug Contributing factor (2)
5
NFIRS–4
Revision 01/01/04
Possibly mentally disabled
3 only if the injury occurred inside the building but not in the area of origin.
You will6 complete
Mdisabled
Physically
(3)
7
Physically
restrained
Enter the8 story
where the casualty wasContributing
at thefactor
start
of the incident.
Unattended person
M1
mpt
before control
after control
7
Contributing
factorInternal
(1)
8 skip
1
Asleep
If you mark
the
box “In area of fire origin,”
the rest of the section and continue on to Section N.
Location at Time of Incident
1
2
3
4
0
U
In area of origin and not involved
Not in area of origin and not involved
Not in area of origin, but involved
In area of origin and involved
Other location
Undetermined
M3
Story at Start of Incident
Complete ONLY if injury occurred INSIDE
Story at start of incident
M4
Below grade
Story Where Injury Occurred
Stories are numbered with 1 representing
level.Below
A “Below
grade” box is marked if that
Story where injury the
occurred,ground
if
grade
different from M
General Location at Time of Injury
M2story
is below grade. For an ordinary residential basement, enter 1 for “Story at start of incident” and
Skip to
1 mark
the
“Below
where
the atinjury
is different from the story at the
In area
of fire
origin grade” box.
Specific
Location
Time ofoccurred
Injury
Section If
N the
M5story
2
In building, but not in area
Complete ONLY
if casualty
NOT in area of origin
4
.
start
of
the
incident,
enter
that
information
in
M
Skip to
3
Outside, but not in area
3
U
parent Symptom
only, asphyxiation
and smoke inhalation
only
ceration
or sprain
Undetermined
Block M5
Specific location at time of injury
O
Primary Area of Body Injured
P
Disposition
4-8
Transported to emergency care facility
1
2
3
4
Head
Neck and shoulder
Thorax
Abdomen
Remarks
Local option
OR
17
Asleep
Contributing factor (3)
or tripped
4
Physically restrained
Other, multiracial
G Date and Time of Injury
0
28
Unconscious
pped
5
Unattended
person
U
Date of Birth
Undetermined
d
Date of Injury
Time of Injury
3
Possibly
impaired
by
alcohol
lapse
U
Contributing factor (2)
Ethnicity
4
Possibly
impaired
by
other
drug
ontact with object
E
2
5at Time
Possibly
mentally disabled Month StoryDayat StartYear
of Incident
1
Hispanic or Latino
Month
Day
Year
Hour
Minute
Injured
of Incident
or
strain
M1 Location
M3 Complete
6 of origin
Physically
1
In area
and notdisabled
involved
Non Hispanic or Latino
0
NFIRS
ONLY5.0
if injurySelf-Study
occurred INSIDEProgram
es
2
Not7in areaPhysically
of origin and
not involved
Contributing factor (3)
restrained
Story at start of incident
3
Below grade
Not8in areaUnattended
of origin, but person
involved
d
4
Factors
Contr
Cause of Injury
In area of origin and involved
None
pt
I
J Human
K Factors
0
Other location
Contributing to Injury
to Injury
Story Where Injury Occurred
M
4
1
Exposed to fire products including flame
U
Undetermined
Injuredcontrol M1 Location at Time of Incident
Story at Start of Incident
Enter up to three contributing
before
MStory
3 where
heat,
smoke,
gas
injury
occurred, and
if
1
In area of origin and not involved
MM
DD
YYYY ONLY if injury occurred INSIDE
NFIRS–4
Below grade
Complete
after control
different
from M3
at Time of Injury
Delete
Exposed
to
toxic
fumes
other
than
smoke
2
A NotLocation
Check
all
applicable
boxes
M2 2General
in area of origin and not involved
Civilian Fire
start of incident
3Story atJumped
in Station
escape attempt
3
Below grade
Not
but involved
Incident Number
Incident Date
FDIDin area of origin,
State
Contributing factor (1)
Casualty
Change
1ExposureAsleep
Skip to
4
1
In
area
of
origin
and
involved
4
Fell,
slipped,
or
tripped
In area of fire origin
pt
Section N
M
5 Specific Location at Time of Injury
2
Unconscious
0
Other
location
2
Caught
or trapped
Story
Where
Injury
Occurred
In building, but not in area
ONLY if casualty
NOT
in area of origin
M56 4 Complete
3
Possibly impaired by alcohol
U5
Undetermined
Skip to
3
Structural collapse
Outside,
but not
in area
Casualty
Gender
Block M5
Injured
Person
4
Possibly impaired
other drug Contributing factor (2)
dbefore control
Story where injury occurred, if
B
C byNumber
7
Struck
by
or
contact
with
object
Below
grade
U
Undetermined
after control
different from M3
General
Location
at
Time
of
Injury
1
2
Male
Female
5
Possibly mentally disabled
Specific location at time of injury
M2
Overexertion or strain
8
6
Physically disabled
9
Multiple causes
Skip to
Contributing factor (3)
7
Physically
restrained
In First
area
of fire origin
Specific
Location at Time of Injury
arent Symptom 1
Casualty Number
Name
Name
Suffix
Section N
0MI5 Last
Other
Disposition
M
Primary
Area
of
Body
Injured
O but not in area
PU Complete
2
8
Unattended person
In building,
ONLY if casualty NOT in area of origin
Undetermined
Skip to
3
Outside, but not in area
only, asphyxiation
Block M5
Race Transported to emergency care facility
E1
Affiliation
U
Undetermined
nd smoke inhalation
Age
or
Date
of
Birth
1
Head
1
White
D
F
location
at timeInjured
of injury
at Time of Incident
H Severity M3 Story at Start of Incid
Activity
When
nly
M1 Location
L Specific
1
Civilian
2
Neck and shoulder 2
Black, African American
1
In area of origin and not involved
Complete ONLY if injury occurred I
Local option 2
eration
EMS, not
department
3
Thorax
2 fire Not
in area of origin and not involved
3
Am.Remarks
Indian, Alaska Native
arent
Symptom
Disposition
Months
(for infants)
Primary
Area
of
Body
Injured
r sprain
Minor
1
Story
at start of incident
3
Police
3
Not
in
area
of
origin,
but
involved
1
O
P
4
Abdomen
Escaping
4
Asian
Age
Moderate
2
In area of origin and involved
0
Other 4
2 Hawaiian,
5
Spine
Rescue
attempt
Native
Other
5
only,
asphyxiation
0
ly
Severe
Transported
3
Pacific
3 Islander
6
Upper extremities
Fire control to emergency care facility Other location
Midnight is 0000.
M4 Story Where Injury O
nd smoke inhalation
OR
Undetermined
17
Head
Date and Time Uof Injury
Life threatening
4
4
Lower
extremities
Return
to
fire
before
control
mptom
is
NOT
found
above
Other,
multiracial
G
0
1
nly
Story where injury occurred, if
2
Neck and shoulder U
Death
5
5
Return to fireLocal
after
control
Date of8Birth Internal
Undetermined
different from M3
Date
of Injury
Time of Injury
General Location
at Time of Injury
option
eration
Remarks
39
Thorax
M
2
Undetermined
U
6
Multiple body parts
Sleeping
Ethnicity
r sprain
4
Abdomen
NFIRS–4 Revision 01/01/04
E2 1 Hispanic
7
Unable to act
Skip to
1Year In area ofHour
or Latino
fire origin
Month 5
DaySpine Year
Month
Day
Minute
Section N
M5 Specific Location at
8
Irrational act
y
2
Non
Hispanic
or
Latino
0
In
building,
but
not
in
area
6
Upper extremities
Complete ONLY if casualty NOT i
0
Other
Skip to
3
Outside, but not in area
7
Lower extremities
mptom is NOT found above
Block M5
U
Undetermined
U
Undetermined
8
Internal
Factors
Contributing
of Injury
None
None Specific location at time of injury
I 9CauseMultiple
J Human
K Factors
body parts
Contributing to Injury
to Injury
NFIRS–4
Revision
01/01/04
Exposed to fire products including flame
1
Primary Apparent Symptom
Enter up to three contributing factors
heat, smoke, and gas
N
O Primary Area of Body Injured P Disposition
Exposed to toxic fumes other than smoke Check all applicable boxes
2
01
Smoke only, asphyxiation
Transported to emer
3
Jumped in escape attempt
Contributing factor (1)
11 1 Burns
and smoke inhalation
Asleep
1
Head
Fell, slipped, or tripped
4
12 2 Burns
only
Unconscious
2
Neck and shoulder
5
Caught or trapped
Local option
21 3 Cut,Possibly
laceration
impaired by alcohol
Remarks
3
Thorax
Structural collapse
6
factor (2)
33 4 Strain
or sprain
Possibly
impaired by other drug 4Contributing
Abdomen
7
Struck by or contact with object
96 5 Shock
Possibly mentally disabled
5
Spine
Overexertion or strain
8
98 6 Pain
only
Physically
disabled
6
Upper extremities
Multiple causes
9
factor (3)
7
Physically restrained
7Contributing
Lower
extremities
Look up a code only if the symptom is NOT found above
Other
0
8
Unattended person
8
Internal
Undetermined
U
9
Multiple body parts
If the injury happened in the building but did not occur in the area of fire origin, complete Block
M.
Enter the description and code found in the CRG which best explains the location.
The code set table used for this data element is the same set that is used for Area of Fire Origin - D
in the Fire Module. Please see the codes listed for the data element found in the CRG.
Section N: Primary Apparent Symptom
Primary apparent symptom
L
Activity When Injured
M1
Location at Time of Incident
1
2
3
4
0
U
In area of origin and not involved
M3
Not in area of origin and not involved
Not in area of origin, but involved
In area of origin and involved
Other location
Undetermined
M4
Story at Start of Incident
Complete ONLY if injury occurred INSIDE
Use
Section
N to record the symptom of the most apparent serious
injury. Section N lists several
of
Story at start of incident
Below grade
1
Escaping
the2 most
common
Rescue
attempt symptoms along with specific identifying codes. Check the appropriate box.
3
Fire control
Story Where Injury Occurred
Return to fire
before control
If 45the primary
symptom
is not on the list, look for a suitable code Story
in where
theinjury
CRG.
the appropriate
occurred,Enter
if
Below grade
Return to fire after control
different from M
General Location at Time of Injury
M
2
code
on
the
line
provided.
6
Sleeping
3
7
8
0
U
Unable to act
Irrational act
Other
Undetermined
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
M5
Specific Location at Time of Injury
Section O: Primary Area of Body Injured
Complete ONLY if casualty NOT in area of origin
Skip to
Block M5
Specific location at time of injury
Primary Apparent Symptom
N
01
11
12
21
33
96
98
Smoke only, asphyxiation
Burns and smoke inhalation
Burns only
Cut, laceration
Strain or sprain
Shock
Pain only
Look up a code only if the symptom is NOT found above
Primary apparent symptom
O
Primary Area of Body Injured
P
Disposition
Transported to emergency care facility
1
2
3
4
5
6
7
8
9
Head
Neck and shoulder
Thorax
Abdomen
Spine
Upper extremities
Lower extremities
Internal
Multiple body parts
Remarks
Local option
NFIRS–4
4-9
Revision 01/01/04
4
5
6
7
8
ontact with object
or strain
es
Injured
Possibly impaired by other drug
Possibly mentally disabled
Physically disabled
Physically restrained
Unattended person
Contributing factor (3)
NFIRS 5.0 Self-Study Program
M1
M2
1
2
3
U
arent Symptom
only, asphyxiation
nd smoke inhalation
nly
eration
r sprain
y
ptom is NOT found above
1
2
3
4
0
U
In area of origin and not involved
M3
Story at Start of Incident
Complete ONLY if injury occurred INSIDE
Not in area of
and not involved
Use Section
Oorigin
to identify
the areaStory
ofatthe
body that sustainedBelowthe
most serious injury.
start of incident
grade
Not in area of origin, but involved
pt
before control
after control
Location at Time of Incident
In area of origin and involved
MakeOther
onelocation
choice from the nine M
listed
in the section. It should be the same part of the body affected
4 Story Where Injury Occurred
Undetermined
by the Primary Apparent SymptomStoryinwhereSection
injury occurred,N.
if
Below grade
General Location at Time of Injury
In area of fire origin
In building, but not in area
Outside, but not in area
Undetermined
Skip to
Section N
Skip to
Block M5
different from M3
M5
Specific Location at Time of Injury
Section P: Disposition
Complete ONLY if casualty NOT in area of origin
Specific location at time of injury
O
Primary Area of Body Injured
P
Disposition
Transported to emergency care facility
1
2
3
4
5
6
7
8
9
Head
Neck and shoulder
Thorax
Abdomen
Spine
Upper extremities
Lower extremities
Internal
Multiple body parts
Remarks
Local option
Mark the box in this section if the casualty was transported to an emergency care facility.
If you are using paper forms instead of the software program, use the space on the forms to supply
additional remarks.
NFIRS–4
Revision 01/01/04
SUMMARY
The Civilian Fire Casualty Module captures data regarding any civilian (nonfire service) casualty
associated with fire-related incidents. If civilian injuries or deaths are recorded in H1 of the Basic
Module, then you are required to complete the Civilian Fire Casualty Module.
A civilian casualty can be a private citizen, emergency medical responder (nonfire department), or
police officer who dies or is physically injured as the result of a fire-related incident. This description
is not meant to exclude other people who fall into this category. For instance, any number of public
and emergency services personnel may be on the scene of an emergency, such as public works personnel, State highway personnel, and other Federal, State, or local employees/officials.
4-10
NFIRS 5.0 Self-Study Program
EXAMPLE: Burn Victim
Directions: Read the call information in the example below. Then look at the completed Civilian Fire Casualty Module
form. Look at each section and follow along with the proper use of the information as applicable to the Civilian Fire Casualty
Module.
At 2135 hours on October 31, 2000, FDID #TR200 Ambulance 29 received a call at 2918 Kilroy
Ave., Norman, OK, for a burn victim. Upon arrival, the crew found a 28-year-old white male
with severe burns on the hands.
The victim was cooking dinner after having a couple of beers and fell asleep leaving the food
unattended. His smoke detector sounded and woke him up. The victim saw a grease fire on the
stove and tried to extinguish it. After trying unsuccessfully picking up the pan to move to the
sink, he was able to reach under the kitchen cabinet and remove a fire extinguisher. He then successfully extinguished the fire.
The grease fire caused second-degree burns to hands, fingers, and the chest area. Ambulance 29
called for an engine company to check for fire extension to the cabinets. Ambulance 29 treated
and transported the patient, Mike Johnson, to the Regan Burn Center for further treatment. The
engine company found no extension and returned to service at 2200 hours.
The incident number, 8797051, was assigned to Station #2.
4-11
NFIRS 5.0 Self-Study Program
A TR200
OK
FDID
State
MM
DD
10
YYYY
31
2000
Incident Date
MI
Age or Date of Birth
028
Months (for infants)
Age
E1
1
2
3
4
5
Date of Birth
I
Year
F
Black, African American
Am. Indian, Alaska Native
Asian
Native Hawaiian, Other
Pacific Islander
E2
1
0
Hispanic or Latino
Non Hispanic or Latino
X
M1
Escaping
Rescue attempt
Fire control
Return to fire before control
Return to fire after control
Sleeping
Unable to act
Irrational act
Other
Undetermined
M2
1
2
3
U
X
EMS, not fire department
Police
Other
Month
Time of Injury
Day
2 0 0 0
Year
Human Factors
Contributing to Injury
J
K
None
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
63
X Asleep
1
2
3
4
5
6
7
8
X
Not in area of origin and not involved
Not in area of origin, but involved
In area of origin and involved
Other location
Undetermined
M3
In area of fire origin
In building, but not in area
Outside, but not in area
Undetermined
Skip to
Section N
Contributing factor (2)
Contributing factor (3)
Story at Start of Incident
Complete ONLY if injury occurred INSIDE
Story at start of incident
M4
Below grade
Story Where Injury Occurred
Story where injury occurred, if
different from M3
General Location at Time of Injury
Check ONE box. If undetermined,
leave blank and skip to Section N.
Improper Use
Cooking Equipment
Contributing factor (1)
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
X
2 1 3 5
Hour
Check all applicable boxes
Location at Time of Incident
1
2
3
4
0
U
Midnight is 0000.
Date and Time of Injury
31
Severity
H
X Civilian
1
2
3
0
10
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
Ethnicity
Cause of Injury
L
G
Other, multiracial
Undetermined
X Exposed to fire products including flame
2
3
4
5
6
7
8
9
0
U
1
2
3
4
5
6
7
8
0
U
Day
0 0 1
Casualty Number
Suffix
Race
0
U
Casualty
Number
C
Female
Last Name
X White
OR
Month
Change
Johnson
First Name
D
2
NFIRS–4
Civilian Fire
Casualty
Delete
Exposure
Gender
1 X Male
Mike
000
Incident Number
Station
Injured Person
B
1
8 7 9 7 0 5 1
002
M5
Below grade
Specific Location at Time of Injury
Complete ONLY if casualty NOT in area of origin
Skip to
Block M5
Specific location at time of injury
Primary Apparent Symptom
N
01
11
12
21
33
96
98
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
Regan Burn Center
NFIRS–4
4-12
Revision 01/01/04
NFIRS 5.0 Self-Study Program
EXERCISE SCENARIO 4-1: Market Street Fire
Directions: Read the call information in the exercise below. Use the information provided to complete the Civilian Casualty
Module form. Compare your work to the answers provided on the completed Structure Fire Module form. If your answers are
different from the ones provided, read over the Civilian Casualty Module again.
At 2:36 a.m. on December 25, 1997, the 911 center receives a telephone call reporting a fire in a
building at 1326 Market Street, (12345 zip code). The East Wind, Wisconsin, Fire Department (FDID
#TR100, Station #2) is dispatched and responds with two engines, one truck, and one deputy chief,
a total of 12 personnel. The dispatch center receives additional calls reporting a fire at this location
and dispatches one engine from the Lakeview Fire Department (FDID #11077).
Engine 422 arrives on the scene at 2:41 a.m. and reports a two-story single-family dwelling of
approximately 2,000 square feet. Fire is showing on the first floor. The crew from Engine 422
advances a 1-3/4-inch line to the fire, searching for occupants as they proceed.
D/C Depew arrives on the scene at 2:42 a.m. and assumes command of the incident. Truck 42
arrives at 2:43 a.m. The truck company is split into two crews. One crew performs search and
rescue and the other performs ventilation. When the crews complete their initial tasks, they do
salvage and overhaul.
Engine 425 arrives on the scene at 2:44 a.m., lays a supply line to Engine 422, and takes a hydrant.
The crew then takes a 1-3/4-inch line to the second floor and finds that the fire has extended into
a bedroom. The extension was through existing balloon framing and combustible insulation.
D/C Depew determines the fire is under control at 3:01 a.m.
The Truck Company Captain reports that most of the family escaped the fire when they heard the
smoke detectors sounding. (Detectors were hardwired with battery back up.) The search and rescue team from Truck 42 found one white male victim - 60 year old Robert Thomas - in a second
story bedroom. They carried the victim down stairs and outside to safety.
Mr. Thomas was treated for smoke inhalation by the East Wind Fire Department EMT’s on the
scene. He improved and was transported by private ambulance to the Mercy Hospital Emergency
Room. Mr. Thomas stated later that he had been on the sofa drinking alcohol and watching television. He also stated that he had been smoking earlier in the evening and left the ashtray on the
sofa when he went to bed at 1 a.m. The estimated time of Mr. Thomas’ injury was 2:30 p.m.
The investigator determined that the fire started in the living room where the couch was located.
It appeared that the ashtray fell into the couch cushions and a smoldering cigarette started the
fire. Building property loss was estimated at $65,000; loss to contents, $15,000.
Mr. Robert Thomas was the recorded occupant of the home. His phone number is 888/5555555. The owner of the dwelling is P&K Development Corporation of Parrot Island, Florida. Their
phone number is 888/235-8888. Ms. Laurie Burnetti of 1 Mango Drive is their agent.
An incident number of 9706231 was assigned to the call, which had no exposures. Engine 422
cleared the scene at 3 a.m. and was available for duty at 3:25 a.m. Truck 42 cleared the scene at
3:20 a.m. and was available at 3:45 a.m. D/C Depew cleared the scene at 3:35 a.m. and was available at 3:36 a.m. and Engine 425 cleared at 3:50 a.m. and was available at 4:10 a.m.
The value of the property is set at $185,000 and contents at $47,000. There is no loss as a result
of the fire.
4-13
NFIRS 5.0 Self-Study Program
MM
A
DD
Delete
FDID
State
Incident Date
Station
Gender
1
Male
First Name
MI
Age or Date of Birth
D
Months (for infants)
Age
E1
Date of Birth
Month
Day
Year
Race
0
U
Other, multiracial
Undetermined
F
G
Affiliation
1
2
3
0
E2
1
0
Date of Injury
Hispanic or Latino
Non Hispanic or Latino
Cause of Injury
1
Exposed to fire products including flame
heat, smoke, and gas
Exposed to toxic fumes other than smoke
Jumped in escape attempt
Fell, slipped, or tripped
Caught or trapped
Structural collapse
Struck by or contact with object
Overexertion or strain
Multiple causes
Other
Undetermined
J
M1
Midnight is 0000.
Time of Injury
Escaping
Rescue attempt
Fire control
Return to fire before control
Return to fire after control
Sleeping
Unable to act
Irrational act
Other
Undetermined
Month
Day
Year
Human Factors
Contributing to Injury
Hour
None
K
Severity
Minor
Moderate
Severe
Life threatening
Death
Undetermined
1
2
3
4
5
U
Minute
Factors Contributing
to Injury
None
Enter up to three contributing factors
Check all applicable boxes
1
2
3
4
5
6
7
8
Asleep
Unconscious
Possibly impaired by alcohol
Possibly impaired by other drug
Possibly mentally disabled
Physically disabled
Physically restrained
Unattended person
Location at Time of Incident
1
2
3
4
0
U
Casualty Number
H
Civilian
EMS, not fire department
Police
Other
Date and Time of Injury
Casualty
Number
C
Female
Ethnicity
I
1
2
3
4
5
6
7
8
0
U
2
Change
Suffix
White
Black, African American
Am. Indian, Alaska Native
Asian
Native Hawaiian, Other
Pacific Islander
Activity When Injured
Exposure
Last Name
1
2
3
4
5
OR
L
Incident Number
Injured Person
B
2
3
4
5
6
7
8
9
0
U
NFIRS–4
Civilian Fire
Casualty
YYYY
In area of origin and not involved
Not in area of origin and not involved
Not in area of origin, but involved
In area of origin and involved
Other location
Undetermined
M2
General Location at Time of Injury
1
2
3
U
In area of fire origin
In building, but not in area
Outside, but not in area
Undetermined
Check ONE box. If undetermined,
leave blank and skip to Section N.
Skip to
Section N
M3
Contributing factor (1)
Contributing factor (2)
Contributing factor (3)
Story at Start of Incident
Complete ONLY if injury occurred INSIDE
Story at start of incident
M4
Below grade
Story Where Injury Occurred
Story where injury occurred, if
different from M3
M5
Below grade
Specific Location at Time of Injury
Complete ONLY if casualty NOT in area of origin
Skip to
Block M5
Specific location at time of injury
Primary Apparent Symptom
N
01
11
12
21
33
96
98
Smoke only, asphyxiation
Burns and smoke inhalation
Burns only
Cut, laceration
Strain or sprain
Shock
Pain only
Look up a code only if the symptom is NOT found above
Primary apparent symptom
O
Primary Area of Body Injured
P
Disposition
Transported to emergency care facility
1
2
3
4
5
6
7
8
9
Head
Neck and shoulder
Thorax
Abdomen
Spine
Upper extremities
Lower extremities
Internal
Multiple body parts
Remarks
Local option
NFIRS–4
4-14
Revision 01/01/04
NFIRS 5.0 Self-Study Program
A TR100
WI
FDID
State
MM
DD
12
YYYY
25
1997
Incident Date
MI
Age or Date of Birth
060
Months (for infants)
Age
E1
1
2
3
4
5
Date of Birth
I
F
Black, African American
Am. Indian, Alaska Native
Asian
Native Hawaiian, Other
Pacific Islander
E2
1
0
Hispanic or Latino
Non Hispanic or Latino
X
M1
Escaping
Rescue attempt
Fire control
Return to fire before control
Return to fire after control
Sleeping
Unable to act
Irrational act
Other
Undetermined
M2
1
2
3
U
X
EMS, not fire department
Police
Other
Month
Time of Injury
Day
1 9 9 7
Year
Human Factors
Contributing to Injury
J
K
None
X
Minor
Moderate
Severe
Life threatening
Death
Undetermined
Minute
Factors Contributing
to Injury
X None
Enter up to three contributing factors
X Asleep
1
2
3
4
5
6
7
8
X
Contributing factor (1)
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
X
0 2 3 0
Hour
1
2
3
4
5
U
Check all applicable boxes
Location at Time of Incident
1
2
3
4
0
U
Midnight is 0000.
Date and Time of Injury
25
Severity
H
X Civilian
1
2
3
0
12
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
Ethnicity
Cause of Injury
L
G
Other, multiracial
Undetermined
X Exposed to fire products including flame
2
3
4
5
6
7
8
9
0
U
1
2
3
4
5
6
7
8
0
U
Year
0 0 1
Casualty Number
Suffix
Race
0
U
Day
Casualty
Number
C
Female
Last Name
X White
OR
Month
Change
Thomas
First Name
D
2
NFIRS–4
Civilian Fire
Casualty
Delete
Exposure
Gender
1 X Male
Robert
000
Incident Number
Station
Injured Person
B
1
9 7 0 6 2 3 1
002
Not in area of origin and not involved
Not in area of origin, but involved
In area of origin and involved
Other location
Undetermined
M3
In area of fire origin
In building, but not in area
Outside, but not in area
Undetermined
Skip to
Section N
Contributing factor (3)
Story at Start of Incident
Complete ONLY if injury occurred INSIDE
002
Story at start of incident
M4
M5
Below grade
Story Where Injury Occurred
Story where injury occurred, if
different from M3
General Location at Time of Injury
Check ONE box. If undetermined,
leave blank and skip to Section N.
Contributing factor (2)
002
Below grade
Specific Location at Time of Injury
Complete ONLY if casualty NOT in area of origin
Skip to
Block M5
21
Bedroom
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
Mercy Hospital, ER,
treated at the scene
and then transported by
private ambulance
NFIRS–4
4-15
Revision 01/01/04
NFIRS 5.0 Self-Study Program
EXERCISE SCENARIO 4-2: Cary Street Fire
Directions: Read the call information in the exercise below. Use the information provided to complete the entire Civilian Fire
Casualty Module form and the other required forms. Compare your work to the answers provided in Appendix A. If your answers
are different from the ones provided, read over the Civilian Fire Casualty Module again.
The Alberta Fire Department (FDID #92188) received a call for a reported house fire at 5 East
Cary Street, Brunswick, Virginia 23351, on May 1, 2005. The dispatcher assigned the incident
(#5433) to Engine 1, Engine 2, and Truck 1 from Shift A, Station 2. The units received the alarm
at 12:53 p.m. and arrived at the scene at 1:05 p.m. Each piece of apparatus was staffed with four
firefighters.
The owner of the single-family dwelling, Mrs. Christy A. Gordon, said that she was warming her
lunch on the stove when the grease from the pan began to burn. The gas stove was a Whirlpool,
Model RF330PXVN, Serial Number F925888840, Year 2000. The fire spread from the pan to the
curtains. She had fallen asleep upstairs and was alerted when the hardwired smoke detector activated. The flame damage was confined to the kitchen. The 2,000-square-foot, two-story home
was filled with smoke in the other rooms. She called 9-1-1. The firefighters extinguished the
fire and removed smoke from the other rooms. The fire was brought under control at 1:25 p.m.
There was $24,000 fire loss to property and $9,600 content loss. The value of the property was
$161,000 and the content value was $80,400. The last unit cleared the scene at 2:40 p.m. FF1
Adam C. Wallner, Badge No. 224, completed the report after returning to Station No. 2. Captain
Tonya S. Gordon, Badge No. 105, was the officer in charge. The fire department keeps records on
the location of all responses. The incident was in Census Tract 501.10, District A12.
Mrs. Gordon, 66-year old, white female, was overcome by smoke in her bedroom. She had problems finding the exit because of the smoke. Her injury occurred at 12:50 p.m. Fire department
personnel treated her at the scene. Her injury was considered minor, but since she said that she
felt dizzy, a local EMS provider transported her to the Proctor Medical Hospital for observation.
4-16
NFIRS 5.0 Self-Study Program
MM
A
C
Delete
Incident Date
State
Location Type
Station
Incident Number
Exposure
NFIRS–1
Number/Milepost
Prefix
Basic
No Activity
Check this box to indicate that the address for this incident is provided on the Wildland Fire
Module in Section B, “Alternative Location Specification." Use only for wildland fires.
Street address
Intersection
In front of
Rear of
Adjacent to
Directions
US National Grid
Census Tract
-
Street or Highway
Street Type
Suffix
Apt./Suite/Room
City
State
ZIP Code
Cross Street, Directions or National Grid, as applicable
Incident Type
E1
Incident Type
D
YYYY
Change
FDID
B
DD
Aid Given or Received
None
Dates and Times
Midnight is 0000
Month
Check boxes if
dates are the
same as Alarm
Date.
Day
Year
Hour
E2
Min
Shifts and Alarms
Local Option
ALARM always required
Shift or
Platoon
Alarm
Alarms
District
ARRIVAL required, unless canceled or did not arrive
1
2
3
4
5
Mutual aid received
Auto. aid received
Mutual aid given
Auto. aid given
Other aid given
Their FDID
Last Unit
Cleared
G1
Resources
Primary Action Taken (1)
G2
Apparatus
Personnel
Suppression
Additional Action Taken (2)
Civilian Fire Cas.–4
Fire Service Cas.–5
EMS–6
HazMat–7
Wildland Fire–8
Apparatus–9
Personnel–10
Arson–11
Check box if resource counts include aid
received resources.
H1
Casualties
None
Deaths Injuries
Fire
Service
Civilian
H2
1
2
U
Detector
Required for confined fires.
Detector alerted occupants
Detector did not alert them
Unknown
H3
1
2
3
4
5
6
7
8
0
Special
Study Value
Estimated Dollar Losses and Values
LOSSES:
Required for all fires if known.
Optional for non-fires.
Property
$
,
,
Contents
$
,
,
None
PRE-INCIDENT VALUE: Optional
EMS
Other
Additional Action Taken (3)
Special
Study ID#
LAST UNIT CLEARED, required except for wildland fires
Check this box and skip this block if an
Apparatus or Personnel Module is used.
Fire–2
Structure Fire–3
Local Option
Controlled
Actions Taken
Completed Modules
Special Studies
CONTROLLED optional, except for wildland fires
Their
State
Their Incident Number
F
E3
Arrival
Property
$
,
,
Contents
$
,
,
Hazardous Materials Release
None
Natural gas: slow leak, no evacuation or HazMat actions
Propane gas: <21-lb tank (as in home BBQ grill)
Gasoline: vehicle fuel tank or portable container
Kerosene: fuel burning equipment or portable storage
Diesel fuel/fuel oil: vehicle fuel tank or portable storage
Household solvents: home/office spill, cleanup only
Motor oil: from engine or portable container
Paint: from paint cans totaling <55 gallons
Other: special HazMat actions required or spill > 55 gal
(Please complete the HazMat form.)
I
Mixed Use
Property
10
20
33
40
51
53
58
59
60
63
65
00
Not mixed
Assembly use
Education use
Medical use
Residential use
Row of stores
Enclosed mall
Business & residential
Office use
Industrial use
Military use
Farm use
Other mixed use
Property Use
None
Structures
Church, place of worship
131
Restaurant or cafeteria
161
Bar/tavern or nightclub
162
Elementary school, kindergarten
213
High school, junior high
215
College, adult education
241
Nursing home
311
Hospital
331
341
342
361
419
429
439
449
459
464
519
Clinic, clinic-type infirmary
Doctor/dentist office
Prison or jail, not juvenile
1- or 2-family dwelling
Multifamily dwelling
Rooming/boarding house
Commercial hotel or motel
Residential, board and care
Dormitory/barracks
Food and beverage sales
539
571
579
599
615
629
700
819
882
891
Household goods, sales, repairs
Gas or service station
Motor vehicle/boat sales/repairs
Business office
Electric-generating plant
Laboratory/science laboratory
Manufacturing plant
Livestock/poultry storage (barn)
Non-residential parking garage
Warehouse
Outside
Playground or park
124
Crops or orchard
655
Forest (timberland)
669
Outdoor storage area
807
Dump or sanitary landfill
919
Open land or field
931
936
938
946
951
960
961
962
Vacant lot
Graded/cared for plot of land
Lake, river, stream
Railroad right-of-way
Other street
Highway/divided highway
Residential street/driveway
981
984
Construction site
Industrial plant yard
J
4-17
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
Phone Number
Last Name
Suffix
Street or Highway
Street Type
Apt./Suite/Room
Post Office Box
State
Area Code
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
4-18
NFIRS 5.0 Self-Study Program
A
MM
FDID
B
DD
YYYY
Incident Date
State
Station
Property Details
B1
C
Not Residential
Incident Number
On-Site Materials
or Products
Change
Exposure
None
Enter up to three codes. Check one box for each code
entered.
On-Site Materials
Storage Use
On-site material (1)
1
2
3
4
U
Bulk storage or warehousing
Processing or manufacturing
Packaged goods for sale
Repair or service
Undetermined
On-site material (2)
1
2
3
4
U
Bulk storage or warehousing
Processing or manufacturing
Packaged goods for sale
Repair or service
Undetermined
1
2
3
4
U
Bulk storage or warehousing
Processing or manufacturing
Packaged goods for sale
Repair or service
Undetermined
Buildings not involved
Number of buildings involved
B3
None
,
Less than one acre
Acres burned (outside fires)
On-site material (3)
D
D1
D2
Ignition
E1
Area of fire origin
Heat source
D3
Item first ignited
1
Check box if fire spread was
confined to object of origin.
Cause of Ignition
Skip to
Section G
Check box if this is an exposure report.
E3
Intentional
Unintentional
Failure of equipment or heat source
Act of nature
Cause under investigation
Cause undetermined after investigation
E2
Factors Contributing to Ignition
3
4
5
None
6
Estimated age of
person involved
Required only if item first
ignited code is 00 or <70
Equipment Involved in Ignition
None
Age was a factor
7
1
Factor contributing to ignition (2)
F1
F2
None
Asleep
Possibly impaired by
alcohol or drugs
Unattended person
Possibly mentally disabled
Physically disabled
Multiple persons involved
1
2
Factor contributing to ignition (1)
Type of material first ignited
Human Factors
Contributing to Ignition
Check all applicable boxes
1
2
3
4
5
U
D4
Fire
Complete if there were any significant amounts of
commercial, industrial, energy, or agricultural products or
or materials on the property, whether or not they became involved
Estimated number of residential living units in
building of origin whether or not all units
became involved
B2
NFIRS–2
Delete
Equipment Power Source
G
2
Male
Fire Suppression Factors
Female
None
Enter up to three codes.
If equipment was not involved, skip to
Section G
Equipment Power Source
Equipment Involved
F3
Brand
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
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
4-19
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.
1
2
3
4
5
6
7
8
0
Enclosed building
Portable/mobile structure
Open structure
Air-supported structure
Tent
Open platform (e.g., piers)
Underground structure (work areas)
Connective structure (e.g., fences)
Other type of structure
Fire Origin
J1
I2
Building Status
1
2
3
4
5
6
7
0
U
Under construction
Occupied & operating
Idle, not routinely used
Under major renovation
Vacant and secured
Vacant and unsecured
Being demolished
Other
Undetermined
J3
Number of stories w/significant damage
(25 to 49% flame damage)
N
None Present
1
Present
U
Undetermined
Detector Type
1
2
3
4
5
0
U
Smoke
Heat
Combination smoke and heat
Sprinkler, water flow detection
More than one type present
Other
Undetermined
M1
Number of stories w/extreme damage
(75 to 100% flame damage)
Detector Power Supply
1
2
3
4
5
6
7
0
U
0
U
L4
Detector Operation
1
Fire too small to activate
2
Operated
Complete
Block L5
3
Failed to operate
Complete
Block L6
U
Undetermined
Type of Automatic Extinguishing System
Required if fire was within designed range of AES
Wet-pipe sprinkler
Dry-pipe sprinkler
Other sprinkler system
Dry chemical system
Foam system
Halogen-type system
Carbon dioxide (CO2) system
Other special hazard system
Undetermined
Width in feet
Type of Material Contributing Most
to Flame Spread
Check if no flame spread OR if
same as Material First Ignited (Block D4,
Fire Module) OR if unable to determine.
K1
Skip to
Section L
Item contributing most to flame spread
M3
K2
Type of material contributing
most to flame spread
L5
Battery only
Hardwire only
Plug-in
Hardwire with battery
Plug-in with battery
Mechanical
Multiple detectors & power
supplies
Other
Undetermined
1
2
3
4
5
6
7
Presence of Automatic Extinguishing System
None Present
N
Present
1
Complete rest of
Section M
2
Partial System Present
U
Undetermined
M2
K
,
BY
Length in feet
Number of stories w/heavy damage
(50 to 74% flame damage)
L3
Skip to
Section M
,
,
Total square feet
,
Total number of stories
below grade
Fire Spread
(In area of the fire)
NFIRS–3
Structure
Fire
OR
Number of stories w/minor damage
(1 to 24% flame damage)
Presence of Detectors
L2
Total number of stories at or
above grade
Story of
fire origin
Confined to room of origin
Confined to floor of origin
Confined to building of origin
Beyond building of origin
L1
Main Floor Size
I4
Count the roof as part of the
highest story.
Count the roof as part of the highest story.
If fire spread was confined to object of origin,
do not check a box (Ref. Block D3, Fire Module).
2
3
4
5
Building
Height
Number of Stories Damaged by Flame
Below grade
J2
I3
1
2
3
4
U
L6
Detector Effectiveness
Required if detector operated.
Alerted occupants, occupants responded
Alerted occupants, occupants failed
to respond
There were no occupants
Failed to alert occupants
Undetermined
Detector Failure Reason
Required if detector failed to operate
1
2
3
4
5
6
0
U
Power failure, shutoff, or disconnect
Improper installation or placement
Defective
Lack of maintenance, includes
not cleaning
Battery missing or disconnected
Battery discharged or dead
Other
Undetermined
Operation of Automatic
Extinguishing System
M5
Required if fire was within designed range
Operated/effective (go to M4)
Operated/not effective (go to M4)
Fire too small to activate
Failed to operate (go to M5)
Other
Undetermined
1
2
3
4
0
U
M4
Number of Sprinkler
Heads Operating
Required if system operated
Required only if item
contributing code is 00 or <70.
Reason for Automatic
Extinguishing System Failure
Required if system failed or not effective
1
2
3
4
5
6
7
8
0
U
System shut off
Not enough agent discharged
Agent discharged but did not
reach fire
Wrong type of system
Fire not in area protected
System components damaged
Lack of maintenance
Manual intervention
Other
Undetermined
Number of sprinkler heads operating
NFIRS–3
4-20
Revision 01/01/06
NFIRS 5.0 Self-Study Program
MM
A
DD
Delete
FDID
State
Incident Date
Incident Number
Station
Gender
1
Male
Injured Person
B
First Name
MI
Age or Date of Birth
D
Months (for infants)
Age
E1
Date of Birth
Month
Day
Year
Race
0
U
Other, multiracial
Undetermined
1
0
Cause of Injury
1
Exposed to fire products including flame
heat, smoke, and gas
Exposed to toxic fumes other than smoke
Jumped in escape attempt
Fell, slipped, or tripped
Caught or trapped
Structural collapse
Struck by or contact with object
Overexertion or strain
Multiple causes
Other
Undetermined
Escaping
Rescue attempt
Fire control
Return to fire before control
Return to fire after control
Sleeping
Unable to act
Irrational act
Other
Undetermined
G
Affiliation
1
2
3
0
J
M1
Midnight is 0000.
Date and Time of Injury
Time of Injury
Month
Day
Year
Human Factors
Contributing to Injury
Hour
None
K
Severity
Minor
Moderate
Severe
Life threatening
Death
Undetermined
1
2
3
4
5
U
Minute
Factors Contributing
to Injury
None
Enter up to three contributing factors
Check all applicable boxes
1
2
3
4
5
6
7
8
Asleep
Unconscious
Possibly impaired by alcohol
Possibly impaired by other drug
Possibly mentally disabled
Physically disabled
Physically restrained
Unattended person
Location at Time of Incident
1
2
3
4
0
U
Casualty Number
H
Civilian
EMS, not fire department
Police
Other
Date of Injury
Hispanic or Latino
Non Hispanic or Latino
I
1
2
3
4
5
6
7
8
0
U
F
Casualty
Number
C
Female
Ethnicity
E2
Activity When Injured
2
Change
Suffix
White
Black, African American
Am. Indian, Alaska Native
Asian
Native Hawaiian, Other
Pacific Islander
L
Exposure
Last Name
1
2
3
4
5
OR
2
3
4
5
6
7
8
9
0
U
NFIRS–4
Civilian Fire
Casualty
YYYY
In area of origin and not involved
Not in area of origin and not involved
Not in area of origin, but involved
In area of origin and involved
Other location
Undetermined
M2
General Location at Time of Injury
1
2
3
U
In area of fire origin
In building, but not in area
Outside, but not in area
Undetermined
Skip to
Section N
M3
Contributing factor (1)
Contributing factor (2)
Contributing factor (3)
Story at Start of Incident
Complete ONLY if injury occurred INSIDE
Story at start of incident
M4
Below grade
Story Where Injury Occurred
Story where injury occurred, if
different from M3
M5
Below grade
Specific Location at Time of Injury
Complete ONLY if casualty NOT in area of origin
Skip to
Block M5
Specific location at time of injury
Primary Apparent Symptom
N
01
11
12
21
33
96
98
Smoke only, asphyxiation
Burns and smoke inhalation
Burns only
Cut, laceration
Strain or sprain
Shock
Pain only
Look up a code only if the symptom is NOT found above
Primary apparent symptom
O
Primary Area of Body Injured
P
Disposition
Transported to emergency care facility
1
2
3
4
5
6
7
8
9
Head
Neck and shoulder
Thorax
Abdomen
Spine
Upper extremities
Lower extremities
Internal
Multiple body parts
Remarks
Local option
NFIRS–4
4-21
Revision 01/01/04
NFIRS 5.0 Self-Study Program
Civilian Fire Casualty Module Test
1. The civilian casualty is a (check all that apply)
(a) firefighter.
(b) private citizen.
(c) emergency medical responder (nonfire department).
(d) police officer.
2. Asleep and physically disabled are examples of this data element.
(a) Primary Apparent Symptom.
(b) Cause of Injury.
(c) Factors Contributing to Injury.
(d) Human Factors Contributing to Injury.
3. Minor and death are examples of this data element.
(a) Severity.
(b) Primary Apparent Symptom.
(c) Disposition.
(d) Age.
4. Sleeping and rescue attempt are examples of this data element.
(a) Factors Contributing to Injury.
(b) Cause of Injury.
(c) Activity When Injured.
(d) Actions Taken.
5. Shock and burns are examples of this data element.
(a) Cause of Injury.
(b) Primary Apparent Symptom.
(c) Factors Contributing to Injury.
(d) Observed Observation.
4-22
| File Type | application/pdf |
| File Modified | 2008-02-12 |
| File Created | 2008-02-12 |