NFIRS 5.0 Self-Study Program: Fire Service Casualty Module: NFIRS-5

NFIRS 5.0 Self-Study Program Fire Service Casualty Module: NFIRS-5

Objectives

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

5-1 Table of Contents

Pretest #5 - Fire Service Casualty Module...... 5-3 Using the Fire Service Casualty Module...... 5-4 Section A: FDID, Incident Number, Exposure...... 5-4 Section B: Injured Person...... 5-4 Section C: Casualty Number...... 5-5 Section D: Age or Date of Birth...... 5-5 Section E: Date and Time of Injury...... 5-5 Section F: Responses...... 5-5 Section G: Usual Assignment, Physical Condition Just Prior To Injury, Severity, Taken To, Activity at Time of Injury ...... 5-6 Section H: Primary Apparent Symptom and Primary Area of Body Injured...... 5-7 Section I: Cause of Firefighter Injury, Factor Contributing to Injury, and Object Involved in Injury...... 5-7 Section J: Where Injury Occurred, Story Where Injury Occurred, Specific Location, and Vehicle Type...... 5-8 Section K: Contribution of Protective Equipment to Injury ...... 5-9 SUMMARY ...... 5-12 EXAMPLE: Highrise Fire...... 5-13 EXERCISE SCENARIO 5-1: Fire Captain Injury on Scene of Fire ...... 5-16 EXERCISE SCENARIO 5-2: Cary Street Fire...... 5-21 NFIRS 5.0 Self-Study Program

Pretest #5 - Fire Service Casualty Module

1. The Fire Service Casualty Module is used to report injuries, deaths, or exposures to fire service, EMS, and other public safety personnel that occur in conjunction with any incident response. (a) True. (b) False.

2. A Basic Module must be completed if the Fire Service Casualty Module is completed. (a) True. (b) False.

3. The Fire Service Casualty Module is a required NFIRS Module. (a) True. (b) False.

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

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

5-3 NFIRS 5.0 Self-Study Program

Using the Fire Service Casualty Module

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

Section A: FDID, Incident Number, Exposure

MM DD YYYY NFIRS–5 Delete A Fire Service FDID State Incident Date Station Incident Number Exposure Change Casualty

TheB informationInjured Person in Section A of the Fire Module is drawn1 Male from Section1 Career A of theC BasicCasualty Module. Number Use Identification Number 2 Female 2 Volunteer the data in the Basic Module to help you supply the requested information. If you are using an auto- Casualty Number matedFirst Name system the data needMI toLast be Name entered only once, then they will beSuffix transferred automatically into other modules that use the data. Midnight is 0000. D Age or Date of Birth E Date and Time of Injury F Responses

Age Date of Injury Time of Injury Date of Birth MM DD YYYY NFIRS–5 A Delete OR Number of prior responses Fire Service Incident Date In years FDID SectionState B: InjuredStation PersonIncident Number Exposureduring past 24 hours Change Month Day Year Month Day Year Hour Minute Casualty

Usual AssignmentInjured Person Physical Condition Just Prior to Injury 1 Male 1 Career Casualty Number 1 B 2 4 Taken To Not transportedC G G Identification Number G2 Female 2 Volunteer 1 Rested 0 Other 1 Hospital 1 Suppression 2 Fatigued U Undetermined 4 Doctor’s office Casualty Number 2 EMS First Name 4 Ill orMI injuredLast Name 5 Morgue/funeralSuffix home 3 Prevention 6 Residence 4 Training Severity 7 Station or quarters Section5 Maintenance B is usedAge to or identifyDateG of3 Birth and classify the person injuredDate or andexposed Time0 ofOther Injuryusing aMidnight variety is 0000. of means.Responses 6 CommunicationsD 1 Report only, including exposureE F 2 First aid only 7 AdministrationAge Date of Birth Date of Injury Activity at TimeTime of ofInjury Injury Start8 completingFire investigation Section B 3by enteringTreated by an physician assigned (no lost identification time) G5 number. While the individual’s 0 Other OR4 Moderate (lost time) Number of prior responses Social Security Number often is used for this purpose, this is not a recommended practice. during past 24 hours In years 5 SevereMonth (lostDay time)Year Month Day Year Hour Minute 6 Life threatening (lost time) Activity at time of injury Next, check the appropriate 7boxesDeath indicating male or female, and the casualty’s affiliation (career or Usual Assignment Physical Condition Just Prior to Injury volunteer).G Paid-per-call1 casualtiesG should2 be considered volunteers whenG 4informationTaken To for this Notsec transported- tion isPrimary entered. Apparent Lastly, Symptom enter the casualty’s1 firstRestedCause and of lastFirefighter0 name,Other Injury middle initial, 1andObject Hospitalany Involved suffix (i.e., Jr., 1 Suppression None H1 2 I1 Fatigued U Undetermined I34 in Doctor’sInjury office Sr., or III) in2 the linesEMS provided. 4 Ill or injured 5 Morgue/funeral home 3 Prevention 6 Residence Primary apparent4 symptomTraining Cause of injury Severity 7 Station or quarters None Primary Part5 of MaintenanceBody Injured G3 Factor Contributing to Injury None 0 Other H2 6 Communications 1 I2 Report only, including exposure 2 First aid only Object involved in injury 7 Administration Activity at Time of Injury 3 Treated by physician (no lost time) Primary injured8 body partFire investigation Contributing factor G5 0 Other 4 Moderate (lost time) 5 Severe (lost time) Where Injury Occurred Specific Location6 Life Where threatening (lost time) Vehicle Type J3 5-4 4 Activity at time of injuryComplete ONLY if J1 Injury Occurred7 Death J 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 incidentPrimary scene Apparent Symptom Complete Cause of Firefighter3 Other Injury FD vehicle Object Involved 63 In rail vehicle Block J4 None H1 I1 4 Non-FD vehicle I3 in Injury 4 En route to medical facility 61 In motor vehicle 5 At scene in structure 54 In sewer Primary apparent symptom53 In tunnel Cause of injury 6 At scene outside Remarks 7 At medical facilityPrimary Part of Body49 Injured In structure None Factor Contributing to Injury 45 In attic None 8 ReturningH 2from incident 00 OtherI2 36 In water UU Undetermined Object involved in injury 9 Returning from med facility 35 In well 0 Other Primary injured body part 34 In ravine Contributing factor U Undetermined 33 In quarry or mine 32 In ditch or trench Specific Location Where Vehicle Type Where Injury Occurred31 In open Jpit3 Complete ONLY if Story WhereJ1 Injury Occurred Injury Occurred J4 Specific Location code J2 28 On steep grade is >60 1 En route to FD location27 On fire escape/outside stairs 1 Suppression vehicle 1 Check this box and enter the story if the 65 In aircraft 2 injury occurred 2inside orAt on aFD structure location 26 On vertical surface or ledge EMS vehicle 25 On ground64 ladder In boat, ship, or barge IfComplete protective equipment failed3 and 3 En route to incident scene Block J4 Other FD vehicle Story of injury Below grade 63 In rail vehicle was a factor in this injury, please 4 En route to medical24 facility On aerial ladder or in basket complete the other side of4 this Non-FD vehicle 23 On roof 61 In motor vehicle 5 At scene in structure form. 22 Outside 54at grade In sewer 2 Injury occurred outside 53 In tunnel NFIRS–5 Revision 01/01/05 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 1 Check this box and enter the story if the 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 NFIRS 5.0 Self-Study Program

MM DD YYYY NFIRS–5 Delete A Fire Service FDID State Incident Date Station Incident Number SectionExposure C: ChangeCasualtyCasualty Number

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

Casualty Number First Name MI Last Name Suffix

MM DD YYYY NFIRS–5 Each casualty is given a number.AMidnight The is 0000. numbers areResponses assigned sequentially starting with one (001), and Delete D Age or Date of Birth E Date and Time of Injury F Fire Service continuing based upon how manyFDID fire serviceState individualsIncident Date were injured orStation killed Incidentat the Number incident, orExposure Change Casualty Age Date of Birth resultingDate of from Injury the incident. Time of Injury OR Number of prior responses Injured Personduring past 24 hours 1 Male 1 Career Casualty Number In years Month Day Year Month Day Year BHour Minute C Identification Number 2 Female 2 Volunteer

Usual Assignment Physical Condition Just Prior to Injury SectionTaken To D: Age or Date of Birth Casualty Number G1 G2 G4 First Name Not transportedMI Last Name Suffix 1 Rested 0 Other 1 Hospital 1 Suppression 2 Fatigued U Undetermined 4 Doctor’s office Midnight is 0000. 2 EMS Age or Date of Birth Date and Time of Injury Responses 4 Ill or injured 5 D Morgue/funeral home E F 3 Prevention 6 Residence 4 Training Age Date of Birth Date of Injury Time of Injury Severity 7 Station or quarters 5 Maintenance G3 0 Other 1 Report only, including exposure OR Number of prior responses 6 Communications during past 24 hours 2 First aid only In years Month Day Year Month Day Year Hour Minute 7 Administration Activity at Time of Injury 3 Treated by physician (no lostMM time) DD5 YYYY NFIRS–5 8 Fire investigation A G Delete 0 Other 4 Moderate (lost time) Fire Service FDID State Incident Date UsualStation AssignmentIncident Number PhysicalExposure Condition Just Prior to Injury 5 Severe (lostEnter time) either the casualty’s ageG 1or date of birth, but Gnot2 both. If the ageChange is entered,Casualty the numbersG4 Taken are To Not transported 6 Life threatening (lost time) assumed to represent years.Activity at time of injury 1 Hospital 7 Death 1 Rested 0 Other 1 Suppression 4 Doctor’s office Injured Person 1 Male 1 Career2 Fatigued CasualtyU UndeterminedNumber B 2 EMS C 5 Morgue/funeral home Identification Number 2 Female 2 Volunteer4 Ill or injured 3 Prevention 6 Residence Primary Apparent Symptom Cause of Firefighter Injury Object Involved 4 Training None 7 Station or quarters H1 I1 I3 in Injury Severity Section5 MaintenanceE: Date andG3 Time of InjuryCasualty Number 0 Other First Name MI Last Name 6 Communications 1Suffix Report only, including exposure Primary apparent symptom Cause of injury 2 First aid only 7 Administration Activity at Time of Injury 3 Treated by physician (no lost time) None 8 Fire investigation Midnight is 0000. G5 Primary Part of Body Injured Age or Date of BirthFactor Contributing to Injury None Date and Time of Injury Responses H2 D I2 0 E Other 4 Moderate (lostF time) Object involved in injury 5 Severe (lost time) Age Date of Birth Date of Injury 6Time of Injury Life threatening (lost time) Activity at time of injury Primary injured body part Contributing factor 7 Death OR Number of prior responses during past 24 hours In years Month Day Year Month Day Year Hour Minute Where Injury Occurred Specific Location Where Vehicle Type J3 J4 Complete ONLY if J1 Injury Occurred Primary Apparent SymptomSpecific Location code Cause of Firefighter Injury Object Involved None H1 is >60 I1 I3 1 En route to FD location 1 in Injury Usual AssignmentEnter the date andPhysical time ofCondition theSuppression injury Just Prior in Sectionvehicleto Injury E. WhenTaken the To injury date is the same as the date of the 2 At FD location G651 In aircraft G2 2 EMS vehicle G4 Not transported 64 In boat, ship, or barge 3 En route to incident scene MM DD YYYYincident, enterComplete 1the sameRested 3date Otherinformation0 Primary FDOther vehicle apparent symptom that youNFIRS–5 entered1 Hospital in the arrivalCause block of injury of Section E1 of the 163 InSuppression rail vehicle Block J4 Delete A4 En route to medical facility 2 Fatigued4 Non-FDU vehicleUndetermined Fire Service4 Doctor’sNone office 261 InEMS motor vehicleBasic Module. If the injury date isPrimary different, Part of then Body enterInjured the correct month,Factor day, Contributing and year. to Injury None FDID State Incident Date Station Incident4 NumberIll or injuredH2 Exposure Change 5 Morgue/funeralI2 home 5 At scene in structure 354 InPrevention sewer Casualty 53 In tunnel 6 Residence Object involved in injury 6 At scene outside 4 Training Remarks 49 In structureThe time, both hoursSeverity and minutes, of the injury is entered using7 Station the 24-hour or quarters clock, where midnight is 0000. 7 At medical facility 5 Maintenance 3 Primary injured body part Contributing factor Injured Person 45 In attic G1 Male 1 Career Casualty Number0 Other B8 Returning from incident 6 Communications00 Other 1 Report only, including exposureC Identification36 In Numberwater UU Undetermined2 2FemaleFirst aid2 onlyVolunteer 9 Returning from med facility 735 InAdministration well ActivitySpecific at Time Loc ofation Injury Where Vehicle Type 3 Treated by physicianWhere (no Injury lost time)Occurred J3 Complete ONLY if 0 Other 834 InFire ravine investigation J1 G5 Injury Occurred J4 Specific Location code 4 Moderate (lost time) Casualty Number is >60 U Undetermined 033 InOther quarry or mine 1 SectionEn route to FD location F: Responses 1 Suppression vehicle First Name MI Last Name 5 Severe (lostSuffix time) 32 In ditch or trench 2 At FD location 65 In aircraft 2 EMS vehicle 31 In open pit 6 Life threatening (lost time) 64 In boat, ship, or barge Story Where Injury Occurred 3 En route to incident sceneActivity at time of injury Complete 3 Other FD vehicle J2 28 On steep grade 7 Death Midnight is 0000. 63 In rail vehicle Block J4 Age or Date of Birth Date and Time of Injury Responses 4 Non-FD vehicle D 27 On fire escape/outsideE stairs 4 En route to medicalF facility 61 In motor vehicle 1 Check this box and enter the story if the injury occurred inside or on a structure 26 On vertical surface or ledge 5 At scene in structure 54 In sewer Date of Injury If protective Timeequipment of Injury failed and Age Date of Birth25 Primary On ground Apparent ladder Symptom 6 CauseAt scene of Firefighter outside Injury 53 In tunnel Object Involved Story of injury was a factor in this injury, please None Remarks Below grade H241 On aerial ladder or in basket I1 49 In structureI3 OR complete the7 other sideAt medicalof this facilityNumber of prior responses in Injury 23 On roof form. during past 24 hours 45 In attic In years Month Day Year Month Day Year Hour8 Returning Minute from incident 00 Other Injury occurred outside 22 Outside at grade 36 In water 2 Primary apparent symptom Cause of injury NFIRS–5 Revision 01/01/05 UU Undetermined 9 Returning from med facility 35 In well Primary Part of Body Injured None 0 FactorOther Contributing to Injury 34 In ravine Usual Assignment H2Physical ConditionRecord Just thePrior number to Injury of incidentsI2 that the casualty respondedNone to within the 24-hour period immedi- G1 G2 G4 TakenU ToUndetermined Not transported 33 In quarry or mine ately prior to the time of injury. 32 In ditchObject or involved trench in injury 1 Rested 0 Other 1 Hospital 31 In open pit 1 Suppression Primary injured body part ContributingStory Where factor Injury Occurred 2 Fatigued U Undetermined 4 J2Doctor’s office 28 On steep grade 2 EMS 4 Ill or injured 5 Morgue/funeral home 27 On fire escape/outside stairs 3 Prevention 6 1 ResidenceCheck this box and enter the story if the 26 On vertical surface or ledge Where Injury Occurred Specific Location Whereinjury occurred inside or on a structure Vehicle Type Complete ONLY if 4 Training J3 4 25 On ground ladder If protective equipment failed and JSeverity1 Injury Occurred7 Station or quarters J Specific Location code was a factor in this injury, please Story of injury Below grade is >60 5 Maintenance G3 0 Other 5-5 24 On aerial ladder or in basket complete the other side of this 11 EnReport route only, to FD including location exposure 1 Suppression vehicle 6 Communications 65 In aircraft 23 On roof form. 22 AtFirst FD aidlocation only 2 EMS vehicle 7 Administration 64 In boat, ship, or bargeInjury occurred outside 22 Outside at grade NFIRS–5 Revision 01/01/05 3 En route to incident scene Activity2 at TimeComplete of Injury 3 Other FD vehicle 8 Fire investigation 3 Treated by physician (no lost time)63 In railG 5vehicle Block J4 4 Non-FD vehicle 0 Other 44 EnModerate route to (lost medical time) facility 61 In motor vehicle 55 AtSevere scene (lost in structure time) 54 In sewer 6 Life threatening (lost time) 53 In tunnel 6 At scene outside Activity at time of injury Remarks 77 AtDeath medical facility 49 In structure 45 In attic 8 Returning from incident 00 Other 36 In water 9 Returning from med facility UU Undetermined Primary Apparent Symptom Cause of Firefighter35 InInjury well Object Involved 0 Other None H1 I1 34 In ravine I3 in Injury U Undetermined 33 In quarry or mine 32 In ditch or trench Primary apparent symptom Cause of injury Story Where Injury Occurred 31 In open pit Primary Part of Body Injured J2 None Factor Contributing28 toOn Injury steep grade H2 I2 27 On fire escape/outsideNone stairs 1 Check this box and enter the story if the injury occurred inside or on a structure 26 On vertical surface or ledgeObject involved in injury 25 On ground ladder If protective equipment failed and Primary injured body part Story of injury ContributingBelow grade factor was a factor in this injury, please 24 On aerial ladder or in basket complete the other side of this 23 On roof form. 22 Outside at grade 2 SpecificInjury occurred Loc outsideation Where Vehicle Type NFIRS–5 Revision 01/01/05 Where Injury Occurred J3 Complete ONLY if J1 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 1 Check this box and enter the story if the 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 MM DD YYYY NFIRS–5 Delete A Fire Service FDID State Incident Date Station Incident Number Exposure Change Casualty

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

Casualty Number NFIRSFirst Name 5.0 Self-Study Program MI Last Name Suffix

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

Section G: Usual Assignment,Age PhysicalDate of BirthCondition JustDate of Injury Prior Time of Injury

OR Number of prior responses To Injury, Severity, TakenIn years To, ActivityMonth atDay TimeYear of Injury during past 24 hours Month Day Year Hour Minute

MM DD YYYY NFIRS–5 Usual Assignment Physical Condition Just Prior Deleteto Injury A G1 G2 Fire ServiceG4 Taken To Not transported FDID State Incident Date Station Incident Number Exposure 1 Rested 0 OtherChange Casualty1 Hospital 1 Suppression 2 Fatigued U Undetermined 4 Doctor’s office 2 EMS 5 Morgue/funeral home MM DD YYYY 4 Ill or injured NFIRS–5 Injured Person 3 Prevention 1 Male 1 Career CasualtyDelete Number 6 Residence AB C Fire Service Identification4 NumberTraining 2 Female 2 Volunteer 7 Station or quarters FDID State Incident Date Station Incident NumberSeverity Exposure Change 5 Maintenance G3 Casualty0 Other 6 Communications 1 Report only, including exposure 2 First aid only Casualty Number First Name MI Last Name7 Administration Suffix Activity at Time of Injury B Injured Person 8 Fire investigation 1 Male3 Treated1 Career by physicianC (no Casualtylost time) NumberG5 Identification0 NumberOther 2 Female4 Moderate2 Volunteer (lost time) Age or Date of Birth Date and Time5 of InjurySevereMidnight (lost istime) 0000. Responses D E 6 F Life threatening (lost time)Casualty Number Activity at time of injury First NameAge MI Last Name Date of Injury 7 Death TimeSuffix of Injury Describe the official assignmentDate ofof Birth the casualty in Block G1. This may or may not coincide with the OR Number of prior responses firefighter’s activity at the time of injury. Midnight is 0000. during past 24 hours In years Month Day PrimaryYear ApparentMonth SymptomDay Year Hour MinuteCause of FirefighterResponses Injury Object Involved D Age or Date of Birth E Date and Time of Injury F None H1 I1 I3 in Injury Age Date of Birth Date of Injury Time of Injury Usual Assignment Physical Condition Just Prior to Injury Primary apparent symptom Taken To Cause of injury G1 OR G2 G4 NumberNot oftransported prior responses In years during past 24 hours Month 1 Day RestedYearPrimary Part0 Month of BodyOtherDay Injured Year None1 HourHospital MinuteFactor Contributing to Injury 1 Suppression H2 I2 None 2 Fatigued U Undetermined 4 Doctor’s office 2 EMS Object involved in injury 4 Ill or injured 5 Morgue/funeral home 3 UsualPrevention Assignment Physical Condition Just Prior to Injury Primary injured body part 6TakenResidence To Contributing factor G41 Training G2 G4 Not transported Severity 7 Station or quarters MM DD YYYY5 Maintenance G3 1 Rested 0 OtherNFIRS–5 10 HospitalOther A Record the1 generalSuppression physical condition1 ofReport the casualty only, including Deletejust exposureprior to theSpecific injury Location in Block Where G2 . Vehicle Type 6 Communications 2 FatiguedWhere InjuryU OccurredUndeterminedFire Service3 4 Doctor’s office Complete ONLY if 2 EMS 1 J J4 Specific Location code FDID State Incident Date 7 AdministrationStation Incident Number 2 JFirstExposure aid only Change Injury 5OccurredMorgue/funeral home 4 Ill or injured Casualty Activity at Time of Injury is >60 38 PreventionFire investigation 3 1 TreatedEn route by physician to FD location (no lost time) G5 6 Residence 1 Suppression vehicle 4 Training 65 In aircraft 0 Other 4 Severity2 ModerateAt FD location(lost time) 7 Station or quarters 2 EMS vehicle Injured Person 5 Maintenance G3 5 Severe (lost time)Casualty Number64 In boat, ship, or barge Complete 3 1 Male 1 Career3 En route to incident scene 0 Other Block J4 Other FD vehicle B 6 Communications 16 ReportLife threatening only, Cincluding (lost time) exposure 63 In rail vehicle Identification Number 2 Female 2 Volunteer4 En route to medical facility Activity at time of injury 4 Non-FD vehicle 7 Administration 27 First aid only 61 In motor vehicle 5 DeathAt scene in structure Activity at Time of Injury 8 Fire investigation 3 Treated by physician (no lost time)54 G In5 sewer 6 At scene outsideCasualty Number 53 In tunnel 0 Other 4 Moderate (lost time) Remarks First Name MI Last Name 5 7SuffixSevereAt medical (lost time) facility 49 In structure Primary Apparent Symptom Cause of Firefighter45 Injury In attic Object Involved None H1 6 8 LifeReturning threateningI1 from (lost incident time) 00 I 3 Other 36 In waterActivity at time of injury in Injury 7 MidnightDeath is 0000. UU Undetermined Age or Date of Birth Date and Time of Injury 9 Returning from medResponses facility 35 In well D PrimaryE apparent symptom 0 Other CauseF of injury 34 In ravine Age Date of Injury TimeU of InjuryUndetermined 33 In quarry or mine Date of Birth Primary ApparentPart of Body Symptom Injured None CauseFactor ofContributing Firefighter toInjury Injury Object Involved DescribeH the12 severity or seriousness of the casualtyI12 in relation to death32 In and ditch timeor trenchNone lostI3 from work in None OR Story Where InjuryNumber Occurredof prior responses 31 In open pit in Injury during past 24 hours Object involved in injury In years Month DayBlock YearG3. Month Day Year JHour2 Minute 28 On steep grade PrimaryPrimary apparentinjured body symptom part ContributingCause of injury factor 27 On fire escape/outside stairs 1 Check this box and enter the story if the injury occurred inside or on a structure 26 On vertical surface or ledge Primary Part of Body Injured None Factor Contributing to Injury If protective equipment failed and Usual Assignment Physical Condition Just Prior to Injury 25 On groundNone ladder 1 2 H2 4 TakenSpecific To LocationStoryI of2 injury WhereNotBelow transported grade Vehicle Type was a factor in this injury, please G G Where Injury Occurred G 3 24 On aerial ladder or in basket Complete completeONLY if the other side of this 1 J J4 Object involved in injury J Injury Occurred 23 On roof Specific Locationform. code 1 Rested 0 Other 1 Hospital is >60 1 Suppression 1 EnPrimary route injured to body FD part location Contributing factor 22 Outside1 Suppression at grade vehicle 2 Fatigued U Undetermined 4 2 Doctor’sInjury occurred office outside NFIRS–5 Revision 01/01/05 2 EMS 2 At FD location 65 In aircraft 2 EMS vehicle 4 Ill or injured 645 InMorgue/funeral boat, ship, or barge home 3 Prevention 3 En route to incident scene 6 Residence Complete 3 Other FD vehicle Where Injury Occurred 63 Specific In rail vehicle Location Where Block J4 Vehicle Type 4 Training 4 En route to medical facility J3 4 Non-FD vehicle Complete ONLY if Severity J1 617 Injury InStation motor Occurred vehicle or quarters J4 Specific Location code 5 Maintenance G3 5 At scene in structure 0 Other is >60 1 Report1 only,En including route to exposure FD location 54 In sewer 1 Suppression vehicle 6 Communications 53 In tunnel 2 First aid26 onlyAt FDscene location outside 65 In aircraft Remarks2 EMS vehicle 7 Administration 6449 Activity In boat,structure at ship, Time or of barge Injury 3 Treated37 by physicianEnAt medicalroute to (no facilityincident lost time) scene Complete 3 Other FD vehicle 8 Fire investigation G56345 In railattic vehicle Block J4 4 UseModerate Block48 (lostGEnReturning4 to routetime) record to from medical whereincident facility the casualty went after00 the Other injury. 4 Non-FD vehicle 0 Other 6136 In motorwater vehicleUU Undetermined 5 Severe59 (lostAtReturning time) scene in from structure med facility 5435 In sewerwell 6 Life threatening0 Other (lost time) 5334 In tunnelravine 6 At scene outside Activity at time of injury Remarks 7 Death 7U AtUndetermined medical facility 4933 In structurequarry or mine 32 In ditch or trench 45 In attic 00 Other 8 Returning from incident 31 In open pit Story Where Injury Occurred 36 In water UU Undetermined 9J2 Returning from med facility 3528 InOn well steep grade Primary Apparent Symptom Cause of Firefighter Injury Object Involved None H1 0 I1Other 3427 InOn ravine fire escape/outsideI3 in Injury stairs 1 Check this box and enter the story if the U injuryUndetermined occurred inside or on a structure 3326 InOn quarry vertical or surface mine or ledge If protective equipment failed and 3225 InOn ditch ground or trench ladder Primary apparent symptom CauseStory of of injury injury Below grade was a factor in this injury, please Story Where Injury Occurred 3124 InOn open aerial pit ladder or in basket complete the other side of this Primary Part of Body Injured NoneJ2 Factor Contributing to Injury2823 On steeproof grade form. 2 2 None H 2 IInjury occurred outside 2722 OnOutside fire escape/outside at grade stairs NFIRS–5 Revision 01/01/05 1 Check this box and enter the story if the injury occurred inside or on a structure 26 On verticalObject surface involved or in injuryledge 25 On ground 5-6ladder If protective equipment failed and Primary injured body part ContributingStory of injury factor 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. Specific LocationInjury occurred Where outside Vehicle22 OutsideType at grade NFIRS–5 Revision 01/01/05 Where Injury Occurred J3 2 Complete ONLY if J1 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 1 Check this box and enter the story if the 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 MM DD YYYY NFIRS–5 Delete A Fire Service FDID State Incident Date Station Incident Number Exposure Change Casualty

B Injured Person 1 Male 1 Career C Casualty Number 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 MM DD YYYY NFIRS–5 Delete 1 Rested 0 Other A 1 Hospital Fire Service 1 Suppression 2 Fatigued U Undetermined 4FDID Doctor’s officeState Incident Date Station Incident Number Exposure Change 2 EMS Casualty 4 Ill or injured 5 Morgue/funeral home 3 Prevention 6 Residence 4 Training NFIRS 5.0 Self-Study Program Severity Injured7 Station Person or quarters 1 Male 1 Career Casualty Number 5 Maintenance G3 B C 0 Other Identification Number 2 Female 2 Volunteer 6 Communications 1 Report only, including exposure 2 First aid only 7 Administration Activity at Time of InjuryMM DD YYYY NFIRS–5 8 Fire investigation 3 Treated by physician (no lost time) AG5 CasualtyDelete Number 4 Moderate (lost time) First Name MI Last Name Suffix Fire Service 0 Other FDID State Incident Date Station Incident Number Exposure 5 Severe (lost time) Change Casualty 6 Life threatening (lost time) Activity at time of injury Midnight is 0000. Responses 7 Death D Age or Date of Birth E Date and Time of Injury F B Injured Person 1 Male 1 Career C Casualty Number Age Date of BirthIdentification Number Date of Injury2 Female 2 VolunteerTime of Injury Use Block G5 to describe what type of activity was taking place at the time the injury occurred. Primary Apparent Symptom Cause of Firefighter Injury OR Object Involved None Number of prior responses H1 I1 I3 Casualtyduring past Number 24 hours In years in InjuryMonth Day Year Month Day Year Hour Minute You will need to enter a code asFirst part Name of the description.MI UseLast Namethe NFIRS Complete Reference Guide (CRG)Suffix Primary apparent symptom to identify theCause activity of injury of the firefighter at the time of the injury. Usual Assignment Physical Condition Just Prior to Injury Midnight is 0000. Primary Part of Body Injured None Factor Contributing toG Injury1 Age or Date of Birth G2 Date and Time of InjuryG4 Taken To NotResponses transported H2 I2 D None E F 1 Hospital Object involved in injury 1 Rested 0 Other 1 Age Suppression Date of Birth Date of Injury Time of Injury 2 Fatigued U Undetermined 4 Doctor’s office Primary injured body part Contributing factor 2 EMS OR 4 Ill or injured 5 Morgue/funeral Numberhome of prior responses 3 Prevention during past 24 hours In years Month Day Year Month Day Year 6 HourResidence Minute Section H: 4PrimaryTraining Apparent Symptom and Where Injury Occurred Specific Location Where Vehicle Type Severity 7 Station or quarters J3 5 Maintenance 3Complete ONLY if J1 Injury Occurred J4 G Specific Location code 0 Other 6 Communications is >601 Report only, including exposure 1 En route to FD location Primary1 UsualSuppression AreaAssignment vehicleof BodyPhysical Injured Condition Just Prior to Injury G71 Administration G2 2 First aid only G4 Taken To Not transported 2 At FD location 65 In aircraft 2 EMS vehicle Activity at Time of Injury 8 Fire investigation 3 Treated by physician (no lost time) G5 1 Hospital 64 In boat, ship, or barge Complete 3 Other FD vehicle 1 Rested 0 Other 3 En route to incident scene Block J4 1 Suppression 4 Moderate (lost time) 63 In rail vehicle 0 Other 2 Fatigued U Undetermined 4 Doctor’s office 4 En route to medical facility 2 4 EMSNon-FD vehicle 5 Severe (lost time) 1 61 Record In motor the vehicle primary symptom and areas of injury in Section H.Ill Use or injured Block H to enter the code that5 Morgue/funeral home 5 64 Life threatening (lost time) At scene in structure 54 In sewer 3 Prevention Activity6 at timeResidence of injury 53 describes In tunnel the casualty’s most serious4 Training injury. 7 Death 6 At scene outside Remarks Severity 7 Station or quarters 7 At medical facility 49 In structure 5 Maintenance G3 0 Other 45 In attic 1 Report only, including exposure 8 Returning from incident 00 Other 6 Communications 36 In water UU Undetermined 7 PrimaryAdministration Apparent Symptom 2 First aid only Cause of Firefighter Injury Object Involved 9 Returning from med facility H1 I1 Activity at TimeI3 of Injury None 35 In well MM DD YYYY 3 Treated by physician (no lost time) 5 in Injury 0 Other 8 Fire investigation NFIRS–5 G A 34 In ravine 4 Moderate (lost time)Delete U Undetermined 33 In quarry or mine 0 Other Fire Service FDID State Incident Date PrimaryStation apparent symptomIncident Number 5 SevereExposure (lost time)Cause of injury 32 In ditch or trench Change Casualty 6 Life threatening (lost time) 31 In open pit Primary Part of Body Injured None Factor Contributing to InjuryActivity at time of injury Story Where Injury Occurred 7 None J2 28 On steep grade H2 Death I2 27Injured The On PersonEmergency fire escape/outside Medical stairs Technician (EMT) or1 theMale person 1responsibleCareer for theCasualty prehospital Number emergency Object involved in injury Check this box and enter the story if the B C 1 26 On vertical surface or ledgeIdentification Number 2 Female 2 Volunteer injury occurred inside or on a structure care phase of treatment may providePrimary you injured with body part a determination of what appearsContributing factorto be the casualty’s 25 On ground ladder If protectivePrimary equipment Apparent failed and Symptom Cause of Firefighter Injury Object Involved was1 a factor in this injury, please 1 3 None Story of injury Below grade 24 On aerial ladder or in basket H I I in Injury most serious injury. complete the other side of this Casualty Number First Name23 On roof MI Last Name form. SpecificSuffix Location Where Vehicle Type Where Injury Occurred J3 Complete ONLY if 2 Injury occurred outside 22 Outside at grade J1 Primary apparent symptom NFIRS–5 RevisionInjury 01/01/05 Occurred Cause of injury J4 Specific Location code is >60 1 En route to FD location None 1 Suppression vehicle Primary Part of Body Injured Midnight is 0000. Factor Contributing to Injury Age or Date of Birth H2 2 At FD locationDate and Time of Injury65 In aircraft I2 Responses 2 EMSNone vehicle D E 64 In boat, ship, or bargeF 3 En route to incident scene Complete 3 Other FD vehicleObject involved in injury 63 In rail vehicle Block J4 Age Date of Birth Date of Injury Time of Injury 4 Non-FD vehicle 4 EnPrimary route injured to body medical part facility 61 In motor vehicle Contributing factor OR 5 At scene in structure 54 In sewer Number of prior responses during past 24 hours In years Month Day Year 6 At sceneMonth outsideDay Year 53 In tunnel SpecificHour Minute Location Where RemarksVehicle Type Block H2 is used to record the bodyWhere part Injury or areaOccurred that sustainedJ493 In the structure most serious injury. It should be Complete ONLY if 7J1 At medical facility Injury Occurred J4 Specific Location code 45 In attic 00 Other is >60 the part of the body affected by18 theEnReturning primary route to from FD apparent location incident symptom. 1 Suppression vehicle Usual Assignment Physical Condition Just Prior to Injury 36 In water UU Undetermined G1 G2 29 AtReturning FD location from med facilityG4 6535Taken In Toaircraftwell Not transported 2 EMS vehicle 64 In boat, ship, or barge 30 EnOther route to incident scene 34 In ravine Complete 3 Other FD vehicle 1 Rested 0 Other 631 InHospital rail vehicle Block J4 1 Suppression U Undetermined 33 In quarry or mine 4 Non-FD vehicle 2 Fatigued4 EnU routeUndetermined to medical facility 614 InDoctor’s motor vehicle office 2 EMS 32 In ditch or trench 4 Ill or injured5 At scene in structure 545 InMorgue/funeral sewer home 3 Prevention 31 In open pit 6 StoryAt scene Where outside Injury Occurred 536 InResidence tunnel 4 Training SectionJ2 I: Cause of Firefighter28 On steep grade Injury, Remarks Severity 7 At medical facility 49277 InOnStation structure fire escape/outside or quarters stairs 5 Maintenance G3 1 Check this box and enter the story if the 450 InOther attic 1 Report 8only,injury Returningincluding occurred inside exposurefrom or on incident a structure 26 On vertical surface00 or ledgeOther 6 CommunicationsFactor Contributing to Injury, and 3625Object InOn water ground Involved ladderUU Undetermined in InjuryIf protective equipment failed and 2 First aid9 onlyReturning from med facility was a factor in this injury, please 7 Administration Story of injury Below grade 3524 Activity InOn well aerial at Time ladder of orInjury in basket 3 Treated0 by physicianOther (no lost time) 34 In ravine complete the other side of this 8 Fire investigation G5 23 On roof form. 4 ModerateU (lostUndetermined time) 33 In quarry or mine 0 Other Injury occurred outside 22 Outside at grade In Section I, record the5 dataSevere that 2(lost describes time) the factors that caused32 In ditchthe injury.or trench Use the CRG to complete NFIRS–5 Revision 01/01/05 6 31 In open pit Life threateningStory (lost Where time) Injury Occurred Activity at time of injury this section. 7 Death J2 28 On steep grade 27 On fire escape/outside stairs 1 Check this box and enter the story if the injury occurred inside or on a structure 26 On vertical surface or ledge 25 On ground ladder If protective equipment failed and Primary Apparent Symptom Cause of Firefighter Injury Object Involved was a factor in this injury, please Story of injury Below grade 24 On aerial ladder or in basket None H1 I1 I3 in Injury complete the other side of this 23 On roof form. 2 Injury occurred outside 22 Outside at grade NFIRS–5 Revision 01/01/05 Primary apparent symptom Cause of injury Primary Part of Body Injured None Factor Contributing to Injury H2 I2 None 1 Use Block I to describe the situation or circumstance that directly resultedObject involved in injury the casualty.

Primary injured body part Contributing factor

Specific Location Where Vehicle Type Where Injury Occurred J3 5-7 Complete ONLY if J1 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 1 Check this box and enter the story if the 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 MM DD YYYY NFIRS–5 Delete A Fire Service FDID State Incident Date Station Incident Number Exposure Change Casualty

B Injured Person 1 Male 1 Career C Casualty Number 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

MM DD YYYY OR NFIRS–5 Number of prior responses Delete A during past 24 hours In years Month Day Year Month Day YearFire Service Hour Minute FDID State Incident Date Station Incident Number Exposure Change Casualty

Usual Assignment Physical Condition Just Prior to Injury G1 G2 G4 Taken To Not transported B Injured Person 1 Male 1 Career C Casualty Number Identification Number 2 Female1 Rested2 Volunteer0 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 Casualty Number First Name MI Last Name Suffix 6 Residence 4 Training Severity 7 Station or quarters 5 Maintenance G3 0 Other 6 Communications 1 Report only,Midnight including is 0000. exposureResponses D Age or Date of Birth E Date and Time2 of InjuryFirst aid only F 7 Administration Activity at Time of Injury 8 Fire investigation 3 Treated by physician (no lost time) G5 Age Date of Birth Date of Injury Time of Injury MM DD YYYY NFIRS–5 0 Other 4 Moderate (lost time)A Delete 5 Fire Service OR Severe (lost time) FDIDNumber of prior responsesState Incident Date Station Incident Number Exposure during past 24 hours Change In years Month Day Year Month Day 6Year Casualty Life threateningHour Minute (lost time) Activity at time of injury 7 Death MM DD YYYY NFIRS–5 Injured Person 1 Male 1 Career CasualtyDelete Number Usual Assignment Physical Condition Just Prior to Injury AB C Fire Service G1 G2 G4 Taken To Not transported Identification Number 2 Female 2 Volunteer Primary Apparent Symptom Cause ofFDID Firefighter InjuryState Incident Date Object InvolvedStation Incident Number Exposure Change 1 1 3 None Casualty 1 H Rested 0 Other 1 IHospitalNFIRS 5.0 Self-Study Program I in Injury 1 Suppression 2 Fatigued U Undetermined 4 Doctor’s office Casualty Number 2 EMS First Name MI Last Name Suffix 4 Ill orPrimary injured apparent symptom 5 Morgue/funeralCause of injuryInjured home Person 1 Male 1 Career Casualty Number 3 Prevention B C 6 Residence Identification Number Female Volunteer 4 Training Primary Part of Body Injured None Factor Contributing to Injury 2 2 SeverityH2 7 IStation2 or quarters None Midnight is 0000. Responses 5 Maintenance G3 0 OtherD Age or Date of Birth E Date and Time of Injury F 6 Communications 1 Report only, including exposure Object involved in injury Casualty Number First Name 2 First aid only Age MI Last Name Date of Injury TimeSuffix of Injury 7 Administration Primary injured body part Activity atContributing Time offactor Injury Date of Birth 8 Fire investigation 3 Treated by physician (no lost time) G5 4 OR Number of prior responses 0 Other Moderate (lost time) Midnight is 0000. during past 24 hours Specific Location WhereInAge years or Date of Birth Month Day Year MonthDate Dayand TimeYear of Injury Hour Minute Responses 5 SevereWhere (lost Injury time) Occurred Vehicle Type Complete ONLY if 1 Enter the code and descriptionJ3 for theD most significantJ4 factor contributing to the Ecasualty’s injury in F 6 J Life threatening (lost time) Injury Occurred Specific Location code Activity at time of injury is >60 Date of Injury Time of Injury 7 1 DeathEn routeBlock to FD I2 .location Age 1 DateSuppression of Birth vehicle 2 At FD location 65 In aircraft Usual Assignment 2 EMS vehiclePhysical Condition Just Prior to Injury Taken To G1 OR G2 G4 NumberNot of transported prior responses 64 In boat, ship, or barge Complete 3 En route to incident scene In years 3 MonthOther FDDay vehicleYear during past 24 hours 63 In rail vehicle Block J4 1 Rested 0 Month OtherDay Year 1 Hour Hospital Minute Primary Apparent Symptom 4 En route to medicalCause facilityof Firefighter Injury 1 ObjectSuppression Involved 4 Non-FD vehicle H1 I1 61 In motor vehicle I3 None 2 Fatigued U Undetermined 4 Doctor’s office 5 At scene in structure 2 in EMSInjury 54 In sewer 4 Ill or injured 5 Morgue/funeral home 6 At scene outside 53 In tunnel 3 UsualPrevention Assignment Physical Condition Just Prior to Injury 1 Remarks 2 4 6TakenResidence To Not transported Primary apparent symptom Cause of injury 49 In structure G4 Training G G 7 At medical facility Severity 7 Station or quarters 45 In attic 5 Maintenance 3 1 Rested 0 Other 1 Hospital Primary Part of Body Injured 8 NoneReturning fromFactor incident Contributing to Injury 00 1 OtherSuppression G 0 Other H2 I2 36 In water NoneUU 6 UndeterminedCommunications 12 FatiguedReport only, includingU Undetermined exposure 4 Doctor’s office 9 Returning from med facility 35 In well 2 EMS 2 First aid only 7Object involvedAdministration in injury 4 Ill or injured 5 Morgue/funeral home 0 Other 34 In ravine 3 Prevention Activity at Time of Injury 8 Fire investigation 3 Treated by physician (no lost time) G5 6 Residence Primary injured body part U UndeterminedContributing factor 33 In quarry or mine 4 Training 0 Other 4SeverityModerate (lost time) 7 Station or quarters 32 In ditch or trench 5 Maintenance G3 5 Severe (lost time) 0 Other 31 In open pit 1 Report only, including exposure3 SpecificStory ThenLocation Where enter Injury Where Occurredthe code and description of6 the objectCommunications that contributed6 to theLife threateninginjury in (lostBlock time) I . Where Injury Occurred 2 28 OnVehicle steep grade Type Complete ONLY if Activity at time of injury J3 J 4 7 Administration 2 First aid only J1 Injury Occurred 27 J On fire escape/outside stairs Specific Location code 7 Death Activity at Time of Injury is >60 3 Treated by physician (no lost time) 5 1 En route to FD location 1 Check this box and enter the story if the 8 Fire investigation G injury occurred inside or on a structure 26 On1 verticalSuppression surface or ledge vehicle 4 Moderate (lost time) 65 In aircraft 0 Other If protective equipment failed and 2 At FD location 25 On2 groundEMS ladder vehicle 5 64 In boat,Story ship, of injury or bargeBelow grade Primary Apparentwas a Symptom factor in this injury, pleaseSevere (lost time)Cause of Firefighter Injury Object Involved 3 En route to incident scene Complete 24 On3 aerialOther ladder FD or invehicle basket complete the other side of this None 63 In rail vehicle SectionBlock J4 J: Where InjuryH1 Occurred, Story6 Life Where threateningI1 (lost Injury time) I3 23 On4 roof Non-FD vehicle form. Activity at time of injury in Injury 4 En route to medical facility 61 In motor vehicle 7 Death 2 Injury occurred outside 22 Outside at grade NFIRS–5 Revision 01/01/05 5 At scene in structure 54 In sewer Primary apparent symptom Cause of injury 6 At scene outside 53 In tunnel Occurred, Specific Location, and Vehicle Type Remarks None 7 At medical facility 49 In structure PrimaryPrimary ApparentPart of Body Symptom Injured CauseFactor ofContributing Firefighter Injuryto Injury None Object Involved None 45 In attic HH12 II12 I3 8 Returning from incident 00 Other in Injury 36 In water UU Undetermined Object involved in injury 9 Returning from med facility 35 In well Section J is completed to describe the location where the injury occurred. PrimaryPrimary apparent injured body symptom part CauseContributing of injury factor 0 Other 34 In ravine U Undetermined 33 In quarry or mine Primary Part of Body Injured None Factor Contributing to Injury 2 2 None 32 In ditch or trench H Specific LocationI Where Vehicle Type Where Injury Occurred J3 Complete ONLY if Story Where Injury Occurred 31 In open pit J1 Injury Occurred J4 Object involved in injurySpecific Location code 2 28 On steep grade is >60 J 1 EnPrimary route injured to body FD part location Contributing factor 1 Suppression vehicle 27 On fire escape/outside stairs 65 In aircraft 1 Check this box and enter the story if the 2 At FD location 2 EMS vehicle injury occurred inside or on a structure 26 On vertical surface or ledge 64 In boat, ship, or barge If protective equipment failed3 andEn route to incident scene Complete 3 Other FD vehicle 25 On ground ladder Where Injury Occurred 63 Specific In rail vehicleLocation Where Block J4 Vehicle Type Story of injury Below grade was a factor in this injury, please J3 4 Non-FD vehicle Complete ONLY if 24 On aerial ladder or in basket complete the other side ofJ4 this1 En route to medical facility 61 Injury In motor Occurred vehicle J4 Specific Location code is >60 23 On roof form. 15 EnAt sceneroute toin FDstructure location 54 In sewer 1 Suppression vehicle Injury occurred outside 22 Outside at grade NFIRS–5 Revision 01/01/05 6553 InIn aircrafttunnel 2 26 AtAt FDscene location outside Remarks2 EMS vehicle 6449 InIn boat,structure ship, or barge 37 EnAt medicalroute to facilityincident scene Complete 3 Other FD vehicle 6345 InIn railattic vehicle Block J4 48 EnReturning route to from medical incident facility 00 Other 4 Non-FD vehicle 6136 InIn motorwater vehicleUU Undetermined 59 AtReturning scene in from structure med facility 5435 InIn sewerwell 0 Other 53 In tunnel 6 At scene outside 34 In ravine Remarks 7U AtUndetermined medical facility 4933 InIn structurequarry or mine 4532 InIn atticditch or trench 8 Returning from incident 00 Other Story Where Injury Occurred 3631 InIn wateropen pit UU Undetermined 9J2 Returning from med facility 3528 InOn well steep grade Mark the boxes in Block J1 to indicate0 whereOther the injury occurred.3427 InOn ravine fire escape/outside stairs 1 Check this box and enter the story if the U injuryUndetermined occurred inside or on a structure 3326 InOn quarry vertical or surfacemine or ledge 3225 InOn ditch ground or trench ladder If protective equipment failed and Story of injury Below grade was a factor in this injury, please Story Where Injury Occurred 3124 InOn open aerial pit ladder or in basket complete the other side of this J2 2823 OnOn steeproof grade form. 2 Injury occurred outside 2722 OnOutside fire escape/outside at grade stairs NFIRS–5 Revision 01/01/05 1 Check this box and enter the story if the 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

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

5-8 MM DD YYYY NFIRS–5 Delete A Fire Service FDID State Incident Date Station Incident Number Exposure Change Casualty

B Injured Person 1 Male 1 Career C Casualty Number 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) MM DD YYYY NFIRS–5 Activity at time of injury 7 Death Delete A Fire Service FDID State Incident Date Station Incident Number Exposure Change Casualty Primary Apparent Symptom Cause of Firefighter Injury Object Involved None H1 I1 I3 in Injury B Injured Person 1 Male 1 Career C Casualty Number Identification Number Female Volunteer Primary apparent symptom2 2 Cause of injury Primary Part of Body Injured None Factor Contributing to Injury H2 I2 Casualty Number None First Name MI Last Name Suffix NFIRS 5.0 Self-Study Program Object involved in injury Primary injured body part Contributing factor Midnight is 0000. D Age or Date of Birth E Date and Time of Injury F Responses Where Injury Occurred Specific Location Where Vehicle Type Age Date of Birth Date of Injury J3 Time of Injury Complete ONLY if J1 Injury Occurred J4 Specific Location code is >60 OR 1 En route to FD location Number of prior responses 1 Suppression vehicle during past 24 hours In years Month Day Year2 At FD locationMonth Day Year 65 InHour aircraft Minute 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 En route to medical facility 4 Non-FD vehicle Usual Assignment Physical Condition Just Prior to Injury 61 In motor vehicle G1 G2 5 At scene in structure G544 Taken In sewer To Not transported 6 At scene outside 53 In tunnel 1 Rested 0 Other 1 Hospital Remarks 1 Suppression 7 At medical facility 49 4 In structureDoctor’s office 2 Fatigued U Undetermined 45 In attic 2 EMS 8 Returning from incident 5 Morgue/funeral00 home Other 4 Ill or injured 36 In water 3 Prevention 9 Returning from med facility 6 Residence UU Undetermined 4 Training 35 In well Severity 0 Other 34 7 In ravineStation or quarters 5 Maintenance G3 U Undetermined 33 0 In quarryOther or mine 6 Communications 1 Report only, including exposure 2 First aid only 32 In ditch or trench 7 Administration 31 Activity In open atpit Time of Injury 3 Treated byStory physician Where (no Injury lost Occurred time) 8 Fire investigation J2 G285 On steep grade 0 Other 4 Moderate (lost time) 27 On fire escape/outside stairs 5 Severe1 (lostCheck time) this box and enter the story if the injury occurred inside or on a structure 26 On vertical surface or ledge 6 If protective equipment failed and Life threatening (lost time) 25 Activity On at time ground of injury ladder Story of injury Below grade was a factor in this injury, please 7 Death 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 Primary Apparent Symptom Cause of Firefighter Injury Object Involved None H1 I1 I3 in Injury Block J3 is used to identify the casualty’s specific location at the time of the injury. Primary apparent symptom Cause of injury Primary Part of Body Injured Note Nonethe codes Factorby the Contributing specific tolocation Injury descriptions. If you selected a vehicle code greater than 60, H2 I2 None also select the vehicle type in J4. Object involved in injury

Primary injured body part Contributing factor

Specific Location Where Vehicle Type Where Injury Occurred J3 Complete ONLY if J1 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 49Block In structure J4 is used to identify the vehicle type that was involved. 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 Section K: Protective Equipment Story Where Injury Occurred 31 In open pit J2 28 On steep grade 27 On fire escape/outside stairs 1 Check this box and enter the story if the injury occurred inside or on a structure 26 On vertical surface or ledge 25Section On ground K allows ladder you to record Ifdata protective involving equipment failed protective and equipment. If protective equipment failed Story of injury Below grade was a factor in this injury, please 24and Oncontributed aerial ladder or toin basket the injury, markcomplete the the other“Yes” side of box this in Block K1. Complete the rest of Section K if you 23 On roof form. 2 Injury occurred outside 22have Outside marked at grade the “Yes” box. 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 Number Please complete the remainder of this form ONLY if you answer YES. No N Casualty

Protective Equipment Item Protective Equipment Problem NOTE:K2 Equipment Sequence Number - When more than one piece of protective equipmentK3 was a factor in the casualty’s injury, a module should be completed for each piece of equipment. Each item is given a number thatCheck is assigned one box to consecutively indicate the main starting problem that occurred. Head or Face Protection Coat, Shirt, or Trousers with one (001) and continuing based on how many protective equipment items were 11involved.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 Apron5-9 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 Fire shelter 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 Equipment NFIRS–5 1 Did protective equipment fail and contribute to the injury? Yes Y K NFIRS 5.0 Self-Study Program Sequence Fire Service Number Please complete the remainder of this form ONLY if you answer YES. 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

70 Special equipment, other failed equipment. Serial Number 00 Protective equipment, other NFIRS–5 Revision 05/01/03

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

5-10 Equipment NFIRS–5 1 Did protective equipment fail and contribute to the injury? Yes Y K Sequence Fire Service NFIRSNumber 5.0 Self-Study Program Please complete the remainder of this form ONLY if you answer YES. No N Casualty

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 Usethan K one3 to item record of protective the most significant problem with the piece of equipment that failed and contrib- 76 Radio distress device Manufacturer utedequipment to the a injury. factor in the 77 Personal lighting injury? If so, complete an 78 Fire shelter 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 5-11 NFIRS–5 Revision 05/01/03 Equipment NFIRS–5 1 Did protective equipment fail and contribute to the injury? Yes Y K Sequence Fire Service Number Please complete the remainder of this form ONLY if you answer YES. No N Casualty

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 NotNFIRS used as5.0 recommended Self-Study Program 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 Fire shelter 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

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

SUMMARY

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

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EXAMPLE: Highrise Fire

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

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Equipment NFIRS–5 1 Did protective equipment fail and contribute to the injury? Yes Y K Sequence Fire Service Number Please complete the remainder of this form ONLY if you answer YES. No N X Casualty

Special Equipment 53 Supply cylinder—insufficient air/oxygen

70 Special equipment, other failed equipment. Serial Number 00 Protective equipment, other NFIRS–5 Revision 05/01/03

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EXERCISE SCENARIO 5-1: Fire Captain Injury on Scene of Fire

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

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MM DD YYYY NFIRS–5 Delete A Fire Service FDID State Incident Date Station Incident Number Exposure Change Casualty

B Injured Person 1 Male 1 Career C Casualty Number 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

Primary Apparent Symptom Cause of Firefighter 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 J3 Complete ONLY if J1 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 1 Check this box and enter the story if the 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

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Equipment NFIRS–5 1 Did protective equipment fail and contribute to the injury? Yes Y K Sequence Fire Service Number Please complete the remainder of this form ONLY if you answer YES. No N Casualty

Special Equipment 53 Supply cylinder—insufficient air/oxygen

70 Special equipment, other failed equipment. Serial Number 00 Protective equipment, other NFIRS–5 Revision 05/01/03

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Special Equipment 53 Supply cylinder—insufficient air/oxygen

70 Special equipment, other failed equipment. Serial Number 00 Protective equipment, other NFIRS–5 Revision 05/01/03

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EXERCISE SCENARIO 5-2: Cary Street Fire

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

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A MM DD YYYY Delete NFIRS–1 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

US 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 Special Studies 1 Mutual aid received Arrival E3 2 Auto. aid received 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

Resources Estimated Dollar Losses and Values F Actions Taken 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 Deaths Injuries Structure Fire–3 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 5 Diesel fuel/fuel oil: vehicle fuel tank or portable storage HazMat–7 Detector 58 H2 6 Business & residential Wildland Fire–8 Required for confined fires. Household solvents: home/office spill, cleanup only 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 807 Outdoor storage area 960 Other street description only if you Code have NOT checked a 919 Dump or sanitary landfill 961 Highway/divided highway Property Use box. 931 Open land or field 962 Residential street/driveway Property Use Description NFIRS–1 Revision 01/01/05

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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? K2 Then check this box and skip 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

L Remarks: 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 Module 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

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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 or 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 2 Processing or manufacturing building of origin whether or not all units 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 D E1 E3 Check box if this is an exposure report. Skip to Contributing to Ignition Section G 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 E2 6 Multiple persons involved Item first ignited 1 Check box if fire spread was 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 1 Not involved in ignition, but burned Some of the information presented in this report may be 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

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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 J1 J3 K Count the roof as part of the highest story. 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 2 3 Confined to floor of origin K 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 0 Other 1 Smoke Required if detector failed to operate U Undetermined 2 Heat 3 Combination smoke and heat Detector Operation 1 Power failure, shutoff, or disconnect L4 2 Improper installation or placement 4 Sprinkler, water flow detection 3 Defective 1 Fire too small to activate 5 More than one type present 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 M1 M3 M5 N None Present Extinguishing System 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 reach fire Required if fire was within designed range of AES 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

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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 fire department Months (for infants) Minor 4 Asian 3 Police 1 Age 2 Moderate 5 Native Hawaiian, Other 0 Other 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 6 Structural collapse 3 Possibly impaired by alcohol 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 3 Fire control 0 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 General Location at Time of Injury different from M3 6 Sleeping M2 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

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MM DD YYYY NFIRS–5 Delete A Fire Service FDID State Incident Date Station Incident Number Exposure Change Casualty

B Injured Person 1 Male 1 Career C Casualty Number 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

Primary Apparent Symptom Cause of Firefighter 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 J3 Complete ONLY if J1 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 1 Check this box and enter the story if the 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

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Equipment NFIRS–5 1 Did protective equipment fail and contribute to the injury? Yes Y K Sequence Fire Service Number Please complete the remainder of this form ONLY if you answer YES. No N Casualty

Special Equipment 53 Supply cylinder—insufficient air/oxygen

70 Special equipment, other failed equipment. Serial Number 00 Protective equipment, other NFIRS–5 Revision 05/01/03

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