Fire Incident Report Form – Fill Out and Use This PDF

Line 1

Fire involved (check):

suspicious circumstance

injury(ies) #

Please submit a casualty report (Form C)

a provincial building

death(s)

#

For ALL civilian and fire fighter casualties

Line 2

Address of the fire:

/

/

street address/lot block and plan #/land location description

RM/town/city name

postal code

Line 3

Date fire occurred:

/

/

Time fire occurred:

am (circle one)

day

month

year

pm

Line 4

RCMP/Municipal Police notified (on death/suspicious fire)

YES

NO

RCMP/Municipal Police contacted:

Phone #:

Line 5 see instructions for line 5

Is the Property Insured

YES

NO If YES, Name of Insurance Company:

Insurance contact person (if known):

Phone #:

Estimated total value of property: $

Estimated damage: $

Insurance File:

Line 6

how they reported

Name of person

the fire to the

their

reporting the fire:

Fire Department:

Phone #:

Line 7

Owner's Name:

Phone #:

first name

middle name/initial

surname

Line 8

Owner's Address:

street address or mailing address

town/city

postal code

Line 9

Occupant's Name:

Apt#:

Phone #:

Line 11

Building height (storeys):

Building area: sqft

Year built:

Line 12

Building occupant load:

# of persons in the building:

Did the fire department rescue occupants : IF YES #

Line 15

Serial number:

License plate # (if vehicle):

Line 16

Name of the manufacturer of the vehicle/equipment involved:

Line 17

Model (number or name):

Year manufactured:

Line 18 (If Equipment)

Date purchased:

time in service:(years)

where installed:

(day/month/year)

OFC01

Line 19 (If Equipment)

Installed by:

certification label & #:

(owner, electrician, gas fitter, company name)

(ULC, CSA, WHI, ULI, AND NUMBER)

Line 20 (If Equipment)

Last inspection/maintenance:

by whom:

(date)

(Owner, Electrician, Gas Fitter, Company Name)

Line 21 (If Equipment)

Action taken as result of last inspection/maintenance:

Line 22 see instructions for line 22

Describe as specifically as possible the following CIRCUMSTANCES of the fire:

Area of Origin:

Level of Origin:

Igniting Object: (What caused ignition)

Cooking equip., heating equip., electrical distribution equip.,

Material First Ignited:(Describe what was ignited)

Structural component, wall/floor/ceiling finish,

furniture, clothing/textile, wood/paper item, flammable/combustible liquid or gas, crops/grass/forest, etc... - please be as specific as possible.

Act or Omission:(Describe what action or inaction caused the fire)

Incendiary, suspicious,

Line 23 see instructions for line 23

Did the building have: (check all that apply)

q smoke alarm(s) If YES what type?

q Battery Operated

q Hardwired

q Interconnected

If a smoke alarm was present, was it:

q in the room of fire origin

q not in the room of fire origin

q fire extinguisher(s)

q standpipe system

q other extinguishing system (describe)

Did the above device(s) or system(s) operate as designed/intended

YES

NO

If NO, explain why (if known)

Line 24 see instructions for line 24

How was the fire discovered:

Line 25 If fire involved grassland, crops, forest or other wildland:

Total Acres burned:

If the fire involved more than one area, indicate:

Acres grassland:

Acres crops:

Acres forest:

Phone Number (work):

(home):

Rank/Title:

Representing: (CIRCLE ONE)

Fire

Police

Insurance

Office of the Fire Commissioner

OFC01

Fire Department Name:

Line 1

Date fire occurred:

/

/

Time fire occurred:

am (circle one)

day

month

year

pm

Line 2

Address of the fire:

/

/

street address/lot block and plan #/land location description

RM/town/city

name

postal code

Line 3

Owner's Name:

Phone #:

first name

middle name/initial

surname

Line 4

Owner's Address:

/

/

street address or mailing address

town/city

postal code

Line 5 see instructions for line 5

Time of alarm:

Time of arrival

Time of arrival

Time all vehicles back "in service":

(1st FD vehicle):

(last FD vehicle):

Line 6

Number of FD vehicles dispatched INITIALLY:

pumpers

aerials

tankers

utility

other

Line 7

Number of FD vehicles dispatched TOTAL#:

pumpers

aerials

tankers

utility

other

Line 8

Distance of fire department response:

km (from fire hall to fire scene)

Line 9

Fire Fighters responded INITIALLY:

Fire Fighters responded TOTAL NUMBER:

Line 10 see instructions for line 10

(circle appropriate)

Mutual Aid: GIVEN

RECEIVED

Fire Protection Agreement Response:

YES

NO

rescue

forcible entry

ventilation

salvage

hydrant used

first aid

extrication

ladder(s) used

overhaul

water tank(er) used

Line 13 see instructions for line 13

Time to control fire:

minutes

Time to extinguish fire:

minutes

Temp:

Wind Direction (blowing to the):

Wind Speed:

Kmh

Name:

/Rank

Phone Number (work):

(home);

OFC01

Saskatchewan

Office of the Fire Commissioner

Fire Casualty Report - Form C

Municipal Affairs,

Culture and Housing

YOU NEED NOT FILL IN LINES 1 & 2 IF ATTACHED TO A BASIC INCIDENT REPORT FORM "A"

Fire Department Name:

Line 1

Date fire occurred:

/

/

Time fire occurred:

am (circle one)

day

month

year

pm

Line 2

Location of the fire:

/

/

street address/lot block and plan #/land location description

RM/town/city name

postal code

Line 3

Casualty’s Name:

Phone #:

first name

middle name/initial

surname

Line 4

Casualty’s Address:

/

/

street address or mailing address

town/city

postal code

Line 5

Casualty is a:

CIVILIAN

FIRE FIGHTER

Line 6

Casualty's Date of Birth:

or Age:

Sex:

Male

or

Female (circle one)

Line 7

Casualty was a:

q

MINOR INJURY

q

LIGHT INJURY

q

SERIOUS INJURY

q

DEATH Date of Death: (if different than date of fire)

Name:

/Rank

Phone Number (work):

(home):