Cole County Fire Protection District

5206 Monticello Road  Jefferson City, MO 65109  573.634.9011  Fax: 573.634.9004

Incident Report Incident No. ______Please Print

Company No. ______Date ______Day: S M T W T F S

Location ______Incident ______

Occupant Name ______Phone # ______On Scene ______

Owner Name ______Phone # ______Clear Scene ______

Address ______In Quarters ______

Nature of Alarm Action Taken — Structure — Good Intent — Injury Accident MVC — Vehicle — Malicious False — Extinguished — Natural Cover — Electrical — Remove Hazard — Rescue — Hazard Condition — Other — Investigate — Standby — Stand By — Assist Ambulance — Other — Return En route — Rescue — Co. Alarms ______

— Mutual Aid: — Given — Received Automatic Alarm: — Line Trouble — Cause Determined — Cause Undetermined

Property Use Construction Type — Private Dwelling — Vehicle — Brick/Stone Number Stories — Multi Dwelling — Shed/Barn — Metal ______— Store/Office — Drive/Parking Lot — Mobile Home Ground Floor Size — Industry/Mfg... — Wood Frame — Vehicle ______— Field/Lawns — Other — Public Place ______

Fire Protection Facilities Was System Effective — Sprinkler System — Residential Smoke Detector — Yes — No — Standpipe — Automatic Detection System

Factor/Material Ignited What Ignited ______Cause of Ignition ______

Contributing Factor of Ignition ______

Equipment Involved ______What Year Make Model Serial # Voltage

Mobile Property ______Year Make Model Serial # License #

Extent of Damage — Flame Damage 1. Object of Origin 5. Building of Origin — Smoke Damage 2. Part of Room of Object of Origin 6. No Damage — Water Damage 3. Floor of Origin — Fire Control 4. Room of Origin Room of Origin ______

What Caused Most Flame ______What Caused Most Smoke ______

Estimated Fire Loss Structure/Object Total Value $______Loss $______Saved $______Contents Total Value $______Loss $______Saved $______Field/Acres Total Value $______Loss $______Saved $______Insurance Company or Agent ______Insurance Coverage ______Structure $ ______Contents $______

Fire Stream and Equipment Report Booster Lines ______Hand Lines 1.5 _____ 2.5 ______Master Streams______Max. Flow Rate (GPM) ______Duration of Flow Rate ______Total Water Applied _____ Gallons Hose 1.5 ______ft 2.5 ______ft 3 ______ft Larger ______ft Hand Extinguishers______Foam ______gal Ladders ______# ______ft. Mask ______Tanks ______Generators ______Lights ______Smoke Ejectors ______Resuscitators/Medical Kits ______Power Tools ______Type ______

Casualty Report Were there any casualties to report? No ______Yes ______If yes, please fill out casualty report. No Fire Service Personnel ______No. Engines ______No. Other Vehicles ______

Rad # Bad # Name On Scene Rad # Bad # Name On Scene 110 01 D. Braun 181 97 N. Luebbering 111 02 G. Smith 182 98 P. Luebbering 112 03 W. Hammann 186 102 N. Otto 113 51 T. Kempker 187 103 J. Suthoff 114 05 M. Rackers 189 105 J. Veit 115 85 D. Kempker 191 113 C. Ousley, Jr. 116 07 S. Cearlock 117 08 G. Hammann 118 09 R. Hammann 120 11 B. Protzman 121 76 G. Woodson Note: Sign Return En Route Sheet at Station. 122 13 S. Barnes 123 06 G. Braun 1101 1201 1301 1401 1501 1601 1701 124 04 S. Braun 126 17 L. Rizner 1110 1210 1310 1410 1510 1610 1710 127 18 R. Gordon 1120 1220 1311 1420 1520 1620 1720 128 19 J. Call 129 20 B. Braun 1121 1320 1431 1621 1721 131 22 L. Barnard 1102 1622 132 23 J. Struemph 133 61 J. Turner 134 25 B. Wilbers NARRATIVE: Description of incident, fire department action and tactics, your 135 62 B. Mehroff company action and sketch of incident. (Use additional sheets if necessary) 136 79 Jason Hammann 137 63 M. Gerstner 138 80 Josh Hammann 139 30 M. Hart 140 122 M. Long 141 32 M. Tellman 142 108 J. Strickland 143 34 P. Tichelkamp 144 35 A. Braun 145 109 C. Angerer 146 115 E. Berendzen 147 116 D. Evers 148 40 S. Gerstner 149 71 D. Rackers 150 112 M. Robinett, Sr. 151 114 M. Robinett, Jr. 152 120 John Moore 153 121 T. Whitener 154 James Moore 155 47 C. Rackers 156 49 C. Hammann 157 107 J. Kempker 158 52 D. Berendzen 159 53 L. Engelbrecht 160 54 S. Kempker 161 67 B. Schulte 162 68 J. Kliethermes 163 69 B. Kliethermes 164 70 R. Werdehausen 165 83 S. York 166 60 L. Sanning 167 81 Dan Berendzen 169 86 Da. Luebbering 170 87 G. Bax 171 88 A. Cortvrient DNR (HOT) 172 P. Hintch 573634-2436 PREPARED BY 173 J. Suess 174 C. Gerstner NRC (HOT) 175 J. Trapani 800-424-8802 176 OFFICER IN CHARGE 177 94 Do. Luebbering CHEMTREC 178 37 L. Benz 800-424-9300 179 95 J. Luebbering APPROVED BY (ASSISTANT CHIEF) 180 96 My. Luebbering FFAM (INS) 202-724-7620