Appendix A PAPER FORMS FOR NFIRS 5.0 MODULES

NFIRS 5.0 COMPLETE REFERENCE GUIDE MM DD YYYY Delete NFIRS–1 A Change FDID Incident Date Station Incident Number Basic State Exposure No Activity

Location Type Check this box to indicate that the address for this incident is provided on the Wildland Fire Census Tract - B Module in Section B, “Alternative Location Specification." Use only for wildland fires. Street address Intersection In front of Number/Milepost Prefix Street or Highway Street Type Suffix Rear of - Adjacent to Apt./Suite/Room City State ZIP Code Directions U.S. National Grid Cross Street, Directions or National Grid, as applicable

Incident Type Dates and Times Midnight is 0000 Shifts and Alarms C E1 E2 Month Day Year Hour Min Local Option Incident Type Check boxes if ALARM always required dates are the Shift or Alarms District Aid Given or Received None same as Alarm Alarm D Date. Platoon ARRIVAL required, unless canceled or did not arrive 1 Special Studies Mutual aid received Arrival 3 2 Auto. aid received E Local Option Their FDID Their CONTROLLED optional, except for wildland fires 3 Mutual aid given State 4 Auto. aid given Controlled Special Special 5 Other aid given Last Unit LAST UNIT CLEARED, required except for wildland fires Study ID# Study Value Their Incident Number Cleared

Actions Taken Resources Estimated Dollar Losses and Values F G1 G2 Check this box and skip this block if an Required for all fires if known. Apparatus or Personnel Module is used. LOSSES: Optional for non-fires. None Primary Action Taken (1) Property $ , , Apparatus Personnel Suppression Contents $ , , Additional Action Taken (2) EMS PRE-INCIDENT VALUE: Optional Other Property $ , , Additional Action Taken (3) Check box if resource counts include aid Contents $ , , received resources.

Completed Modules Casualties None Hazardous Materials Release None Mixed Use H1 H3 I Not mixed Fire–2 Property –3 Deaths Injuries 10 Assembly use Fire 1 Natural gas: slow leak, no evacuation or HazMat actions Civilian Fire Cas.–4 20 Education use Service 2 Propane gas: <21-lb tank (as in home BBQ grill) 33 Medical use Fire Service Cas.–5 3 Gasoline: vehicle fuel tank or portable container 40 Residential use Civilian EMS–6 4 Kerosene: fuel burning equipment or portable storage 51 Row of stores 53 Enclosed mall HazMat–7 5 Diesel fuel/fuel oil: vehicle fuel tank or portable storage Detector 58 Business & residential 2 6 home/office spill, cleanup only Wildland Fire–8 H Required for confined fires. Household solvents: 59 Office use 7 Motor oil: from engine or portable container 60 Industrial use Apparatus–9 1 Detector alerted occupants 8 Paint: from paint cans totaling <55 gallons 63 Military use Personnel–10 2 Detector did not alert them 0 Other: special HazMat actions required or spill > 55 gal 65 Farm use U Unknown Arson–11 (Please complete the HazMat form.) 00 Other mixed use

J Property Use None 341 Clinic, clinic-type infirmary 539 Household goods, sales, repairs Structures 342 Doctor/Dentist office 571 Gas or service station 131 Church, place of worship 361 Prison or jail, not juvenile 579 Motor vehicle/boat sales/repairs 161 Restaurant or cafeteria 419 1- or 2-family dwelling 599 Business office 162 Bar/Tavern or nightclub 429 Multifamily dwelling 615 Electric-generating plant 213 Elementary school, kindergarten 439 Rooming/Boarding house 629 Laboratory/Science laboratory 215 High school, junior high 449 Commercial hotel or motel 700 Manufacturing plant 241 College, adult education 459 Residential, board and care 819 Livestock/Poultry storage (barn) 311 Nursing home 464 Dormitory/Barracks 882 Non-residential parking garage 331 Hospital 519 Food and beverage sales 891 Warehouse Outside 936 Vacant lot 981 Construction site 124 Playground or park 938 Graded/Cared for plot of land 984 Industrial plant yard 655 Crops or orchard 946 Lake, river, stream Look up and enter a 669 Forest (timberland) 951 Railroad right-of-way Property Use code and Property Use Outdoor storage area description only if you Code 807 960 Other street have NOT checked a 919 Dump or sanitary landfill 961 Highway/Divided highway Property Use box. Property Use Description 931 Open land or field 962 Residential street/driveway NFIRS–1 Revision 01/01/05 K1 Person/Entity Involved Local Option Business Name (if applicable) Area Code Phone Number

Check this box if same address as incident Mr., Ms., Mrs. First Name MI Last Name Suffix location (Section B). Then skip the three duplicate address lines. Number Prefix Street or Highway Street Type Suffix

Post Office Box Apt./Suite/Room City

State ZIP Code More people involved? Check this box and attach Supplemental Forms (NFIRS–1S) as necessary.

Owner Same as person involved? 2 Then check this box and skip K the rest of this block. Local Option Business Name (if applicable) Area Code Phone Number

Check this box if same address as incident location (Section B). Mr., Ms., Mrs. First Name MI Last Name Suffix Then skip the three duplicate address lines. Number Prefix Street or Highway Street Type Suffix

Post Office Box Apt./Suite/Room City

State 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:

Buildings 111 Complete Fire & Structure Modules Special structure 112 Complete Fire Module & Section I, Structure Module Confined 113–118 Basic Module Only Mobile property 120–123 Complete Fire & Structure Modules Vehicle 130–138 Complete Fire Module Vegetation 140–143 Complete Fire or Wildland Module Outside rubbish fire 150–155 Basic Module Only Special outside fire 160 Complete Fire or Wildland Module Special outside fire 161–163 Complete Fire Module Crop fire 170–173 Complete Fire or Wildland Module 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 Officer in charge ID Signature Position or rank Assignment Month Day Year same as Officer in charge. Member making report ID Signature Position or rank Assignment Month Day Year MM DD YYYY Delete NFIRS–2 A Fire Change FDID State Incident Date Station Incident Number Exposure

Property Details On-Site Materials Complete if there were any significant amounts of commercial, industrial, energy, or agricultural products B C or Products None or materials on the property, whether or not they became involved. Enter up to three codes. Check one box for each code On-Site Materials Not Residential entered. Storage Use B1 Estimated number of residential living units in 1 Bulk storage or warehousing building of origin whether or not all units 2 Processing or manufacturing 3 Packaged goods for sale became involved. 4 Repair or service On-site material (1) U Undetermined

Buildings not involved 1 Bulk storage or warehousing B2 2 Processing or manufacturing Number of buildings involved 3 Packaged goods for sale 4 Repair or service On-site material (2) U Undetermined

None B3 , 1 Bulk storage or warehousing Acres burned (outside fires) Less than one acre 2 Processing or manufacturing 3 Packaged goods for sale 4 Repair or service On-site material (3) U Undetermined

Ignition Cause of Ignition Human Factors 1 3 D E Check box if this is an exposure report. Skip to E Section G Contributing to Ignition Check all applicable boxes D1 1 Intentional None Area of fire origin 2 Unintentional 1 Asleep 3 Failure of equipment or heat source 2 Possibly impaired by 4 Act of nature alcohol or drugs D2 Heat source 5 Cause under investigation 3 Unattended person U Cause undetermined after investigation 4 Possibly mentally disabled 5 Physically disabled 3 Factors Contributing to Ignition None D 2 6 Multiple persons involved Item first ignited Check box if fire spread was E 1 confined to object of origin. 7 Age was a factor D4 Factor contributing to ignition (1) Estimated age of Type of material first ignited Required only if item first. person involved ignited code is 00 or <70. Factor contributing to ignition (2) 1 Male 2 Female

Equipment Involved in Ignition Equipment Power Source Fire Suppression Factors None F1 F2 G Enter up to three codes. None If equipment was not involved, skip to Section G. Equipment Power Source

Fire suppression factor (1) Equipment Involved Equipment Portability F3 Brand 1 Portable Model Fire suppression factor (2) 2 Stationary Serial # Portable equipment normally can be moved by one or two persons, is designed to be used in Year multiple locations, and requires no tools to install. Fire suppression factor (3)

Mobile Property Involved None Mobile Property Type and Make Local Use H1 H2 Pre-Fire Plan Available Not involved in ignition, but burned Some of the information presented in this report may be 1 based upon reports from other agencies: Mobile property type 2 Involved in ignition, but did not burn 3 Involved in ignition and burned Arson report attached Mobile property make Police report attached Coroner report attached Mobile property model Year Other reports attached

License Plate Number State VIN

Structure fire? Please be sure to complete the Structure Fire form (NFIRS–3). NFIRS–2 Revision 01/01/05 Structure Type Building Status Building Main Floor Size I1 I2 I3 I4 NFIRS–3 If fire was in an enclosed building or a Height Structure portable/mobile structure, complete the Count the roof as part of the rest of this form. Fire 1 Under construction highest story. 1 Enclosed building 2 Occupied & operating 2 Portable/Mobile structure , , 3 Idle, not routinely used Total number of stories at or Total square feet 3 Open structure 4 Under major renovation above grade. 4 Air-supported structure 5 Vacant and secured OR 5 Tent 6 Vacant and unsecured 6 Open platform (e.g., piers) 7 Being demolished BY 7 Underground structure (work areas) Total number of stories , , 0 Other below grade. Length in feet Width in feet 8 Connective structure (e.g., fences) U Undetermined 0 Other type of structure

Fire Origin Number of Stories Damaged by Flame Type of Material Contributing Most 1 3 J J Count the roof as part of the highest story. K to Flame Spread Below grade Number of stories w/minor damage Check if no flame spread OR if Story of Skip to (1 to 24% flame damage) same as Material First Ignited (Block D4, fire origin Fire Module) OR if unable to determine. Section L

Number of stories w/significant damage Fire Spread (25 to 49% flame damage) K1 J2 If fire spread was confined to object of origin, Item contributing most to flame spread do not check a box (Ref. Block D3, Fire Module). Number of stories w/heavy damage (50 to 74% flame damage) 2 Confined to room of origin K2 3 Confined to floor of origin Number of stories w/extreme damage Type of material contributing Required only if item 4 Confined to building of origin (75 to 100% flame damage) most to flame spread contributing code is 00 or <70. 5 Beyond building of origin

Presence of Detectors Detector Power Supply Detector Effectiveness L1 L3 L5 Required if detector operated. (In area of the fire) 1 Battery only 1 Alerted occupants, occupants responded N Skip to None Present Section M 2 Hardwire only 2 Alerted occupants, occupants failed 1 Present 3 Plug-in to respond U Undetermined 4 Hardwire with battery 3 There were no occupants 5 Plug-in with battery 4 Failed to alert occupants Detector Type 6 Mechanical U Undetermined L2 7 Multiple detectors & power Detector Failure Reason supplies L6 1 Smoke 0 Other Required if detector failed to operate. U Undetermined 2 Heat 3 Combination smoke and Operation 1 Power failure, shutoff, or disconnect L4 4 Sprinkler, water flow detection 2 Improper installation or placement 3 Defective 5 More than one type present 1 Fire too small to activate 4 Lack of maintenance, includes 0 Other 2 Operated Complete not cleaning U Undetermined Block L5 5 Battery missing or disconnected 3 Failed to operate Complete 6 Battery discharged or dead Block L6 0 Other U Undetermined U Undetermined

Presence of Automatic Extinguishing System Operation of Automatic Reason for Automatic 1 3 5 M N None Present M Extinguishing System M Extinguishing System Failure Required if fire was within designed range. 1 Present Complete rest of Required if system failed or not effective. Section M 1 Operated/effective (go to M4) 2 Partial System Present 1 System shut off 2 Operated/Not effective (go to M4) U Undetermined 2 Not enough agent discharged 3 Fire too small to activate 3 Agent discharged but did not Type of Automatic Extinguishing System 4 Failed to operate (go to M5) M2 Required if fire was within designed range of AES. reach fire 0 Other 4 Wrong type of system 1 Wet-pipe sprinkler U Undetermined 5 Fire not in area protected 2 Dry-pipe sprinkler 6 System components damaged 3 Other sprinkler system Number of Sprinkler M4 7 Lack of maintenance 4 Dry chemical system Heads Operating 8 Manual intervention 5 Foam system Required if system operated. 0 Other 6 Halogen-type system U Undetermined 7 Carbon dioxide (CO2) system 0 Other special hazard system Number of sprinkler heads operating U Undetermined NFIRS–3 Revision 01/01/06 MM DD YYYY NFIRS–4 Delete A Civilian Fire FDID Incident Date Station Incident Number State Exposure Change Casualty

B Injured Person Gender C Casualty 1 Male 2 Female Number

First Name MI Last Name Suffix Casualty Number

E1 Race Age or Date of Birth Affiliation Severity D 1 White F H 2 Black, African American 1 Civilian 3 Am. Indian, Alaska Native 2 EMS, not Months (for infants) Minor 4 Asian 3 Police 1 Age Moderate 5 Native Hawaiian, Other 0 Other 2 3 Severe Pacific Islander Midnight is 0000. OR Date and Time of Injury 4 Life threatening 0 Other, multiracial G 5 Death Date of Birth U Undetermined Date of Injury Time of Injury U Undetermined Ethnicity E2 Month Day Year 1 Hispanic or Latino Month Day Year Hour Minute 0 Non Hispanic or Latino

I Cause of Injury J Human Factors None K Factors Contributing None Contributing to Injury to Injury 1 Exposed to fire products including flame heat, smoke, and gas Enter up to three contributing factors 2 Exposed to toxic fumes other than smoke Check all applicable boxes

3 Jumped in escape attempt Contributing factor (1) 4 Fell, slipped, or tripped 1 Asleep 5 Caught or trapped 2 Unconscious 3 Possibly impaired by alcohol 6 Structural collapse Contributing factor (2) 7 Struck by or contact with object 4 Possibly impaired by other drug 8 Overexertion or strain 5 Possibly mentally disabled 9 Multiple causes 6 Physically disabled 0 Other 7 Physically restrained Contributing factor (3) U Undetermined 8 Unattended person

Location at Time of Incident L Activity When Injured M1 M3 Story at Start of Incident 1 In area of origin and not involved Complete ONLY if injury occurred INSIDE 2 Not in area of origin and not involved 1 Escaping 3 Not in area of origin, but involved Story at start of incident Below grade 2 Rescue attempt 4 In area of origin and involved 0 3 Other location Story Where Injury Occurred U Undetermined M4 4 Return to fire before control Story where injury occurred, if Below grade 5 Return to fire after control different from M3 2 General Location at Time of Injury 6 Sleeping M 7 Unable to act Skip to 1 In area of fire origin Specific Location at Time of Injury 8 Irrational act Section N M5 2 In building, but not in area 0 Other Complete ONLY if casualty NOT in area of origin 3 Outside, but not in area Skip to U Undetermined Block M5 U Undetermined Specific location at time of injury

N Primary Apparent Symptom O Primary Area of Body Injured P Disposition 01 Smoke only, asphyxiation Transported to emergency care facility 11 Burns and smoke inhalation 1 Head 12 Burns only 2 Neck and shoulder 21 Cut, laceration 3 Thorax Remarks Local option 33 Strain or sprain 4 Abdomen 96 Shock 5 Spine 98 Pain only 6 Upper extremities Look up a code only if the symptom is NOT found above 7 Lower extremities 8 Internal 9 Multiple body parts Primary apparent symptom NFIRS–4 Revision 01/01/04 MM DD YYYY NFIRS–5 Delete A Fire Service FDID State Incident Date Station Incident Number Exposure Change Casualty

Injured Person 1 Male 1 Career C Casualty Number B Identification Number 2 Female 2 Volunteer

Casualty Number First Name MI Last Name Suffix

Midnight is 0000. D Age or Date of Birth E Date and Time of Injury F Responses

Age Date of Birth Date of Injury Time of Injury

OR Number of prior responses during past 24 hours In years Month Day Year Month Day Year Hour Minute

Usual Assignment Physical Condition Just Prior to Injury G1 G2 G4 Taken To Not transported 1 Rested 0 Other 1 Hospital 1 Suppression 2 Fatigued U Undetermined 4 Doctor’s office 2 EMS 4 Ill or injured 5 Morgue/Funeral home 3 Prevention 6 Residence 4 Training Severity 7 Station or quarters 5 Maintenance G3 0 Other 6 Communications 1 Report only, including exposure 2 First aid only 7 Administration Activity at Time of Injury 8 Fire investigation 3 Treated by physician (no lost time) G5 0 Other 4 Moderate (lost time) 5 Severe (lost time)

6 Life threatening (lost time) Activity at time of injury 7 Death

Primary Apparent Symptom Cause of Injury Object Involved None H1 I1 I3 in Injury

Primary apparent symptom Cause of injury Primary Part of Body Injured None Factor Contributing to Injury H2 I2 None Object involved in injury

Primary injured body part Contributing factor

Specific Location Where Vehicle Type Where Injury Occurred 3 Complete ONLY if J1 J Injury Occurred J4 Specific Location code is >60 1 En route to FD location 1 Suppression vehicle 2 At FD location 65 In aircraft 2 EMS vehicle 64 In boat, ship, or barge 3 En route to incident scene Complete 3 Other FD vehicle 63 In rail vehicle Block J4 4 Non-FD vehicle 4 En route to medical facility 61 In motor vehicle 5 At scene in structure 54 In sewer 53 In tunnel 6 At scene outside Remarks 7 At medical facility 49 In structure 45 In attic 8 Returning from incident 00 Other 36 In water UU Undetermined 9 Returning from med facility 35 In well 0 Other 34 In ravine U Undetermined 33 In quarry or mine 32 In ditch or trench Story Where Injury Occurred 31 In open pit J2 28 On steep grade 27 On fire escape/outside stairs Check this box and enter the story if the 1 injury occurred inside or on a structure 26 On vertical surface or ledge 25 On ground ladder If protective equipment failed and Story of injury Below grade was a factor in this injury, please 24 On aerial ladder or in basket complete the other side of this 23 On roof form. 2 Injury occurred outside 22 Outside at grade NFIRS–5 Revision 01/01/05 Equipment NFIRS–5 1 Did protective equipment fail and contribute to the injury? Yes Y K Sequence Fire Service Please complete the remainder of this form ONLY if you answer YES. Number No N Casualty

Protective Equipment Item Protective Equipment Problem K2 K3 Check one box to indicate the main problem that occurred. Head or Face Protection Coat, Shirt, or Trousers 11 Burned 11 Helmet 21 Protective coat 12 Melted 12 Full face protector 22 Protective trousers 13 Partial face protector 23 Uniform shirt 21 Fractured, cracked or broken 14 Goggles/eye protection 24 Uniform T-shirt 15 Hood 25 Uniform trousers 22 Punctured 16 Ear protector 26 Uniform coat or jacket 17 Neck protector 27 Coveralls 23 Scratched 10 Other 28 Apron or gown 20 Other 24 Knocked off Boots or Shoes 25 Cut or ripped 31 Knee length boots with steel baseplate and steel toes 32 Knee length boots with steel toes only 31 Trapped steam or hazardous gas 33 3/4 length boots with steel baseplate and steel toes 34 3/4 length boots with steel toes only 32 Insufficient insulation 35 Boots without steel baseplate and steel toes 33 Object fell in or onto equipment item 36 Safety shoes with steel baseplate and steel toes 37 Safety shoes with steel toes only 41 Failed under impact 38 Non-safety shoes 30 Other 42 Face piece or hose detached Respiratory Protection 43 Exhalation valve inoperative or damaged 41 SCBA (demand) open circuit 42 SCBA (positive pressure) open circuit 44 Harness detached or separated 43 SCBA closed circuit 44 Not self-contained 45 Regulator failed to operate 45 Cartridge respirator 46 Dust or particle mask 46 Regulator damaged by contact 40 Other 47 Problem with admissions valve Hand Protection 48 Alarm failed to operate 51 Firefighter gloves with wristlets 52 Firefighter gloves without wristlets 49 Alarm damaged by contact 53 Work gloves 54 HazMat gloves 51 Supply cylinder or valve failed to operate 55 Medical gloves 50 Other 52 Supply cylinder/valve damaged by contact

Special Equipment 53 Supply cylinder—insufficient air/oxygen

61 Proximity suit for entry 94 Did not fit properly 62 Proximity suit for non-entry 63 Totally encapsulated, reusable chemical suit 95 Not properly serviced or stored prior to use 64 Totally encapsulated, disposable chemical suit 65 Partially encapsulated, reusable chemical suit 96 Not used for designed purpose 66 Partially encapsulated, disposable chemical suit 97 Not used as recommended by manufacturer 67 Flash protection suit 68 Flight or jump suit 00 Other equipment problem 69 Brush suit 71 Exposure suit UU Undetermined 72 Self-contained underwater breathing apparatus (SCUBA) Equipment Manufacturer, Model and Serial 73 Life preserver K4 74 Life belt or ladder belt Number 75 Personal alert safety system (PASS) Was the failure of more than one item of protective 76 Manufacturer Radio distress device equipment a factor in the 77 Personal lighting injury? If so, complete an 78 or tent additional page of this Model 79 Vehicle safety belt form for each piece of 70 Special equipment, other failed equipment. Serial Number 00 Protective equipment, other NFIRS–5 Revision 05/01/03 MM DD YYYY Delete NFIRS–6

A Change EMS FDID State Incident Date Station Incident Number Exposure

Number of Patients Patient Number Date/Time Month Day Year Hour/Min B C Time Arrived at Patient Check if same date as Alarm date Use a separate form for each patient Time of Patient Transfer D Provider Impression/Assessment Check one box only None/no patient or refused treatment 10 Abdominal pain 18 Chest pain 26 Hypovolemia 34 Sexual assault 11 Airway obstruction 19 Diabetic symptom 27 Inhalation injury 35 Sting/Bite 12 Allergic reaction 20 Do not resuscitate 28 Obvious death 36 Stroke/CVA 13 Altered LOC 21 Electrocution 29 OD/Poisoning 37 Syncope 14 Behavioral/Psych 22 General illness 30 Pregnancy/OB 38 Trauma 15 Burns 23 Hemorrhaging/Bleeding 31 Respiratory arrest 00 Other 16 Cardiac arrest 24 Hyperthermia 32 Respiratory distress 17 Cardiac dysrhythmia 25 Hypothermia 33 Seizure

Age or Date of Birth Race Human Factors None Other None E1 F1 G1 Contributing to Injury G2 1 White Factors 2 Black, African American Check all applicable boxes Months (for infants) 3 Am. Indian, Alaska Native If an illness, not an Age 4 Asian 1 Asleep injury, skip G2 and OR 5 Native Hawaiian, Other 2 Unconscious go to H3 Pacific Islander 3 Possibly impaired by alcohol 0 Other, multiracial Month Day Year U Undetermined 4 Possibly impaired by drug 1 Accidental 5 Possibly mentally disabled 2 Self-inflicted Gender Ethnicity 6 Physically disabled 3 Inflicted, not self E2 F2 1 Hispanic or Latino 7 Physically restrained 1 Male 2 Female 2 Non Hispanic or Latino 8 Unattended person

Body Site of Injury Injury Type Cause of 3 H1 List up to five body sites H2 List one injury type for each body site listed under H1 H Illness/Injury

Cause of illness/Injury

Procedures Used Check all applicable boxes No treatment Safety Cardiac Arrest I None K J Equipment 01 Airway insertion 14 Intubation (EGTA) Check all applicable boxes 02 Anti-shock trousers 15 Intubation (ET) Used or deployed by patient. Check all applicable boxes. 1 Pre-arrival arrest? Assist ventilation 16 03 IO/IV therapy If pre-arrival arrest, was it: 04 Bleeding control 17 Medications therapy 1 Safety/Seat belts 1 Witnessed? 05 Burn care 18 Oxygen therapy 2 Child safety seat 2 Bystander CPR? 06 Cardiac pacing 19 OB care/delivery 3 Airbag Cardioversion (defib) manual 20 07 Prearrival instructions 4 Helmet 2 Post-arrival arrest? 08 Chest/Abdominal thrust 21 Restrain patient 5 Protective clothing 09 CPR 22 Spinal immobilization 6 Flotation device Initial Arrest Rhythm 10 Cricothyroidotomy 23 Splinted extremities 0 Other 1 V-Fib/V-Tach 11 Defibrillation by AED 24 Suction/Aspirate U Undetermined 12 EKG monitoring 00 Other 0 Other 13 Extrication U Undetermined

Initial Level of Highest Level of Care Patient Status EMS 1 2 None M Not transported L Provider L Provided On Scene N Disposition 1 Improved 1 First Responder 1 First Responder 2 Remained same 1 FD transport to ECF 2 EMT-B (Basic) 2 EMT-B (Basic) 3 Worsened 2 Non-FD transport 3 EMT-I (Intermediate) 3 EMT-I (Intermediate) 3 Non-FD trans/FD attend 4 EMT-P (Paramedic) Check if: 4 EMT-P (Paramedic) 4 Non-emergency transfer 0 Other provider 1 Pulse on transfer 0 Other provider 0 Other N No Training 2 No pulse on transfer NFIRS–6 Revision 01/01/04 MM DD YYYY Delete NFIRS–7 A HazMat FDID State Incident Date Station Incident Number Exposure Haz No. Change

HazMat ID Chemical B UN Number DOT Hazard CAS Registration Number Name Classification

Container Estimated Container Capacity Estimated Amount Released Physical State C1 None C2 D1 E1 Type When Released , , , , 1 Capacity: by volume or weight Amount released: by volume or weight Solid 2 Liquid Container Type Check one box Check one box 3 Gas 3 Units: Capacity 2 Units: Released C D U Undetermined VOLUME WEIGHT VOLUME WEIGHT More hazardous 11 Ounces 21 Ounces 11 Ounces 21 Ounces Released Into materials? Use 12 Gallons 22 Pounds 12 Gallons 22 Pounds E2 additional sheets. 13 Barrels: 42 gal. 23 Grams 13 Barrels: 42 gal. 23 Grams 14 Liters 24 Kilograms 14 Liters 24 Kilograms 15 Cubic feet MICRO UNITS 15 Cubic feet MICRO UNITS Released into 16 Cubic meters Enter Code 16 Cubic meters Enter Code

None HazMat Actions Taken Complete the remainder F2 Population Density G2 Area Evacuated H of this form only for the Enter up to three actions taken first hazardous material 1 Urban 1 Square feet involved in this incident. , 2 Suburban Blocks 2 Enter Primary action taken (1) 3 Rural 3 Square miles measurement Released From F1 Estimated Number of Additional action taken (2) Area Affected G3 Check all applicable boxes G1 People Evacuated Below grade Additional action taken (3) 1 Square feet , 2 Blocks 1 Inside/on structure If fire or explosion is involved with a 3 Square miles Estimated Number of I release, which occurred first? Story of release G4 Buildings Evacuated , 1 Ignition U Undetermined 2 Outside of structure None Enter measurement , 2 Release

Cause of Release Factors Contributing to Release Factors Affecting Mitigation None J K L Enter up to three factors or impediments that affected the Enter up to three contributing factors mitigation of the incident. 1 Intentional 2 Unintentional release 3 Container/Containment failure Factor contributing to release (1) Factor or impediment (1) 4 Act of nature 5 Cause under investigation Factor contributing to release (2) Factor or impediment (2) U Cause undetermined after investigation

Factor contributing to release (3) Factor or impediment (3)

Equipment Involved None Mobile Property Involved in None HazMat Disposition M in Release N Release O 1 Completed by fire service only 2 Completed w/fire service present Mobile property type Equipment involved in release 3 Released to local agency 4 Released to county agency 5 Released to State agency Brand Mobile property make 6 Released to Federal agency Model 7 Released to private agency Model Year 8 Released to property owner or Serial # manager License plate number State HazMat Civilian Casualties Year P Deaths Injuries DOT number/ ICC number NFIRS–7 Revision 01/01/06 MM DD YYYY Delete NFIRS–8 A Wildland Change FDID State Incident Date Station Incident Number Exposure Fire

Alternate Location Specification Wildland Fire Cause Factors Contributing None B D1 D3 to Ignition Enter Latitude/Longitude OR Township/Range/Section/Subsection Meridian if Section B on the Basic Module is not completed. 1 Natural source 8 Misuse of fire #1 #2 2 Equipment 0 Other U Undetermined Fire Suppression Factors 3 Smoking D4 None Latitude • Longitude • 4 Open/Outdoor fire #1 5 OR Debris/Vegetation burn Enter 6 Structure (exposure) up to #2 North East 7 Incendiary three • South West factors Township Range Human Factors Contributing #3 2 D to Ignition None Check as many boxes as are applicable. Heat Source Section Subsection Meridian E 1 Asleep C Area Type 2 Possibly impaired by alcohol or drugs 3 Unattended person F Mobile Property Type None 1 Rural, farms >50 acres 4 Possibly mentally disabled 2 Urban (heavily populated) 5 Physically disabled Equipment Involved 3 Rural/Urban or suburban None 6 Multiple persons involved G in Ignition 4 Urban-wildland interface area 7 Age was a factor

Weather Information Number of Buildings Ignited 1 4 Primary Crops Burned H I None I Number of buildings that were Identify up to 3 crops if any crops were burned. NFDRS Weather Station ID ignited in Wildland fire.

Number of Buildings Threatened I2 Crop 1 Weather Type Wind Direction None Number of buildings that were threatened by Wildland fire but were not involved. F° Check if Crop 2 Wind Speed (mph) Air Temperature negative Total Acres Burned I3 % % Crop 3 Relative Humidity Fuel Moisture Fire Danger Rating , , •

J Property Management K NFDRS Fuel Model at Origin M Type of Right-of-Way None Indicate the percent of the total acres burned for each owner- Enter the code and the descriptor corresponding Required if less than 100 feet. ship type then check the ONE box to identify the property owner- to the NFDRS Fuel Model at Origin. ship at the origin of the fire. If the ownership at origin is Federal, enter the Federal Agency Code. Feet Horizontal distance Type of right-of-way from right-of-way Ownership % Total Acres Burned Fire Behavior L1 Person Responsible for Fire N U Undetermined % 1 Identified person caused fire These optional descriptors refer to observations 2 Unidentified person caused fire made at the point of initial attack. Private 3 Fire not caused by person If person identified, complete the rest of Section L. 1 Tax paying % Feet Gender of Person Involved Elevation 2 Non-tax paying % L2 1 Male 2 Female Public Relative position on slope 3 Age or Date of Birth % L 3 City, town, village, local Aspect Age in Years Date of Birth 4 County or parish % OR 5 State or province % Month Day Year Feet 6 Federal % Flame length Federal Agency Code Activity of Person Involved 7 Foreign % L4 Chains per Hour 8 Military % Rate of spread % 0 Other Activity of Person Involved NFIRS–8 Revision 01/01/04 NFIRS–9 A MM DD YYYY Delete Change Apparatus or

FDID State Incident Date Station Incident Number Exposure Resources

Apparatus or Dates and Times Midnight is 0000 Sent Number Apparatus Use Actions Taken Check if same date as Alarm date on B Check ONE box for each List up to 4 actions for each Resources the Basic Module (Block E1). of apparatus to indicate its main apparatus. Use codes listed below X Month Day Year Hour/Min People use at the incident.

1 ID Dispatch Suppression Arrival EMS Type Clear Other

2 ID Dispatch Suppression Arrival EMS Type Clear Other

3 ID Dispatch Suppression Arrival EMS Type Clear Other

4 ID Dispatch Suppression Arrival EMS Type Clear Other

5 ID Dispatch Suppression Arrival EMS Type Clear Other

6 ID Dispatch Suppression Arrival EMS Type Clear Other

7 ID Dispatch Suppression Arrival EMS Type Clear Other

8 ID Dispatch Suppression Arrival EMS Type Clear Other

9 ID Dispatch Suppression Arrival EMS Type Clear Other

Medical and Rescue Apparatus or Resource Type Aircraft Ground Fire Suppression 71 Rescue unit 41 Aircraft: fixed-wing tanker 72 Urban search and rescue unit More apparatus? 42 Helitanker 11 Engine 73 High-angle rescue unit Use additional 43 Helicopter 12 Truck or aerial 75 BLS unit sheets. 40 Aircraft, other 13 76 ALS unit 14 Tanker and pumper combination Marine Equipment 70 Medical and rescue unit, other 16 Brush truck 17 ARFF (aircraft rescue and ) 51 Fire boat with pump Other 10 Ground fire suppression, other 52 Boat, no pump 50 Marine equipment, other 91 Mobile command post NN None Heavy Ground Equipment 92 Chief officer car UU Undetermined Support Equipment 93 HazMat unit 21 Dozer or plow 94 Type I hand crew 22 Tractor 61 Breathing apparatus support 95 Type II hand crew 24 Tanker or tender 62 Light and air unit 99 Privately owned vehicle 20 Heavy ground equipment, other 60 Support apparatus, other 00 Other apparatus/resources NFIRS–9 Revision 01/01/04 MM DD YYYY A Delete NFIRS–10 Change Personnel FDID State Incident Date Station Incident Number Exposure

Apparatus or Dates and Times Midnight is 0000 Sent Number Apparatus Use Actions Taken B Check if same date as Alarm date on Resources of Check ONE box for each List up to 4 actions for the Basic Module (Block E1). X apparatus to indicate its main each apparatus and Month Day Year Hour/Min People use at the incident. each personnel.

1 Sent ID Dispatch Suppression Arrival EMS Type Clear Other

Personnel Name Rank or Attend Action Action Action Action Grade Taken ID X Taken Taken Taken

2 Dispatch Sent ID Suppression Arrival EMS Type Clear Other

Personnel Name Rank or Attend Action Action Action Action Grade Taken ID X Taken Taken Taken

3 Dispatch Sent ID Suppression Arrival EMS Type Clear Other

Personnel Name Rank or Attend Action Action Action Action Taken ID Grade X Taken Taken Taken

NFIRS–10 Revision 01/01/04 MM DD YYYY Delete NFIRS–11 A Arson FDID State Incident Date Station Incident Number Exposure Change

B Agency Referred To None Agency Name Their case number

Number Prefix Street or Highway Street Type Suffix Their ORI

Post Office Box Apt./Suite/Room City Their Federal Identifier (FID)

State ZIP Code Agency phone number Their FDID

Availability of Material First Ignited C Case Status D 1 Investigation open 4 Closed with arrest 1 Transported to scene 2 Investigation closed 5 Closed with exceptional 2 Available at scene 3 Investigation inactive clearance U Unknown

Check up to three factors E Suspected Motivation Factors 42 Vanity/Recognition 54 Burglary 11 Extortion 22 Hate crime 43 Thrills 61 Homicide concealment 12 Labor unrest 23 Institutional 44 Attention/Sympathy 62 Burglary concealment 13 Insurance fraud 24 Societal 45 Sexual excitement 63 Auto theft concealment 14 Intimidation 31 Protest 51 Homicide 64 Destroy records/evidence 15 Void contract/lease 32 Civil unrest 52 Suicide 00 Other suspected motivation 21 Personal 41 Fireplay/Curiosity 53 Domestic violence UU Unknown motivation

Apparent Group Involvement Incendiary Devices F None CONTAINER No container Check up to three factors H Select one from each category 1 Terrorist group 11 Bottle (glass) 14 Pressurized container 17 Box 2 Gang 12 Bottle (plastic) 15 Can (not gas or fuel) 00 Other Container 3 Anti-government group 13 Jug 16 Gasoline or fuel can UU Unknown 4 Outlaw motorcycle organization 5 Organized crime IGNITION/DELAY DEVICE No device 6 Racial/Ethnic hate group 11 Wick or fuse 17 Road flare/fuse 7 Religious hate group 12 Candle 18 Chemical component 8 Sexual preference hate group 13 Cigarette and matchbook 19 Trailer/Streamer 0 Other group 14 Electronic component 20 Open flame source U Unknown 15 Mechanical device 00 Other delay device 16 Remote control UU Entry Method Unknown G1 FUEL None

Entry Method 11 Ordinary combustibles 16 Pyrotechnic material Extent of Fire Involvement on Arrival 12 Flammable gas 17 Explosive material G2 14 Ignitable liquid 00 Other material 15 Ignitable solid UU Unknown Extent of Fire Involvement

Other Investigative Information J Property Ownership Initial Observations I K Check all that apply Check all that apply 1 Private 1 Windows ajar 5 Fire department forced entry 1 Code violations 2 City, town, village, local 2 Doors ajar 6 Entry forced prior to FD arrival 2 Structure for sale 3 County or parish 3 Doors locked 7 Security system activated 3 Structure vacant 4 Doors unlocked 8 Security system present 4 State or province (not activated) 4 Other crimes involved 5 Federal 5 Illicit drug activity 6 Foreign Laboratory Used Check all that apply None 6 Change in insurance 7 Military L 7 Financial problem 0 Other 1 Local 3 ATF 5 Other 6 Private 8 Criminal/Civil actions pending 2 State 4 FBI Federal NFIRS–11 Revision 01/01/04