FIRE SAFETY F-15.

11 REG 1

FIRE SAFETY REGULATIONS

5
Appendix B
Form A - Fire Incident Report (Insurance)
Appendix B
[Section 6]
Form A - Fire Incident Report (Insurance)
[Section 6]

E m ergency M anagem ent Basic Fire Incident Report

and Fire Safety P age 1 of 3

F ire D epartm ent: Incident Tim e: Incident D ate:

u s e 2 4 -h o u r c lo c k d a y / m o n th / y e a r

Incident Addre ss: / /

s tre e t a d d re s s /lo t, b lo c k a n d p la n # /la n d lo c a tio n d e s c rip tio n R M /T o w n /C ity /V illa g e /H a m le t p o s ta l c o d e

Incident Type:  Structure Fire  Vehicle Fire  Vegetation Fire  Garbage Fire

 Other:
p ro v id e d e ta il o f fire in c id e n t if n o t c la s s ifie d a b o v e

N ote: Complete and attach to this report a “Fire Detector and Extinguishing Equipment Report” and/or a “Casualty Report” as applicable

M utual Aid  M utual Aid Received  M utual Aid Given

R esources
N um ber of Appara tus N um ber of Personnel
lis t to ta l n u m b e r o f a p p a ra tu s re s p o n d e d lis t to ta l n u m b e r o f p e rs o n n e l re s p o n d e d

Values
Estim ated Dollar Value of Property: $ Estim ated Dollar Value of D am ages: $

Insura nce F ile # Insura nce C om pany:

Persons Involved

Insura nce C ontact: P hone:

Police C ontact: P hone:

O wner’s N am e: P hone:

O wn er’s Ad dress:

O ccupant's N am e P hone:
 F-15.11 REG 1 FIRE SAFETY
FIRE SAFETY REGULATIONS
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Property U se
 Educational  M ercantile / Business  Storage

 Health Care / Detention  Industry / U tility  Outside or special property

 Residential  M anufacturing

 Other
p ro v id e p ro p e rty u s e d eta il o f th e s tru c tu re if n o t c la s s ifie d a b o v e

N um ber of buildings involved Acres burned Building height Floor size

T o ta l # o f sto rie s In d ic a te ft 2 o r m 2

Building Status
 Under Construction  Under m ajor renovation  Being dem olished

 Occupied  Vacant and secured  Undeterm ined

 Idle / Not routinely used  Vacant and unsecured

 O ther
p ro v id e d e ta ils o f b u ild in g s ta tu s if n o t c la s s ifie d a b o v e

C ontinued on Page 2

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 FIRE SAFETY F-15.11 REG 1
FIRE SAFETY REGULATIONS
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E m ergency M anagem ent Basic Fire Incident Report

and Fire Safety P age 2 of 3

Fire Spread  Confined to room of origin  Confined to building of origin

 Confined to floor of origin  Beyond building of origin

M obile Property Involved M obile Property Type

 None  Passenger or road transport  Aircraft

 Not involved with ignition, but burned  Freight road vehicle  Industrial, agriculture, construction

 Involved with ignition, but did not burn  Transport vehicle  M iscellaneous

 Involved with ignition and burned  W ater vessel  Unknown

M obile Pro perty D etails

M ake

M odel

Licence num b er P rovince V IN

Ignition F actors

Are a of O rigin
p ro v id e d e ta ile d d e s c rip tio n o f th e p rim a ry u s e o f th e a re a w h e re th e fire s ta rte d - a ls o c h e c k b e lo w a s a p p lic a b le

 Means of egress  Storage areas  Transportation vehicle areas

> h a llw a y s , e n tra n c e a re a s , fire e x its > s to re ro o m s , c lo s e ts , g a ra g e s > p a s s e n g e r a re a , tru n k , e n g in e

 Assembly areas  Service areas  Outside areas

> th e a te rs , c o m m u n ity h a lls , liv in g ro o m s > c o n d u it, p ip e s , e le v a to r s h a ft > s tre e ts , p a rk in g lo ts , ra ilw a y tra c k s

 Function area  Service or equipment areas  Other areas

> b e d ro o m , k itc h e n , o ffic e , d in in g ro o m > m e c h a n ic a l ro o m s , c e lls > a re a s n o t o th e rw is e lis te d

 Technical processing area  Structural areas  Undetermined

> la b o ra to rie s , o p e ra tin g ro o m s , s ta g e s > a ttic s , c ra w l s p a c e s, e x te rio r o f w a lls > a re a o r o rig in c a n n o t b e d e te rm in e d

H eat So urce
p ro v id e d e ta ile d d e s c rip tio n o f th e h e a t s o u rc e w h ic h ig n ite d th e firs t o b je c t to b u rn - a ls o c h e c k b e lo w a s a p p lic a b le

 Operating equipment  Other open flame, smoker's materials  Other heat sources
> s p a rk , e m b e r, e le c tric a l a rc , ra d ia n t h e a t > c ig a re tte s , c a n d le s , m a tc h , lig h te r > m u ltip le h e a t s o u rc e s

 Hot smouldering object  Chemical, Natural heat sources  Undetermined

> h e a t o f fric tio n , m o lte n m a te ria l, w e ld in g > s u n lig h t, s p o n ta n e o u s co m b u s tio n > h e a t s o u rc e c a n n o t b e d e te rm in e d

 Explosives, fireworks  Heat spread from another fire

> b la s tin g a g e n t, m u n itio n s , fire w o rk s > fla m e c o n ta c t, ra d ia n t h e a t, e m b e rs

Item First Ignited

p ro v id e d e ta ile d d e s c rip tio n o f th e ite m firs t ig n ite d - a ls o c h e c k b e lo w a s a p p lic a b le

 Structural component  Adornment, recreational items, signs  Organic materials

> w a ll c o v e rin g s , fra m in g , flo o r c o v e rin g s > C h ris tm a s tre e s , a w n in g s , te n ts , to y s > a g ric u ltu ra l c ro p s , h u m a n s , a n im a ls

 Furniture, utensils  Storage supplies  General materials

> u p h o ls te ry , c a b in e ts , a p p lia n c e s > b o x e s , p a c k in g m a te ria ls , p a lle ts > b o o k s , tra s h , d u s t, lin t, tire s , fe rtilize r

 Soft goods, wearing apparel  Liquids, piping, filters  Undetermined

> m a ttre s s e s, lin e n , c lo th in g , d ra p e s > fla m m a b le g a s e s / liq u id s , p ip e s , d u c ts > ite m firs t ig n ite d c a n n o t b e d e te rm in e d

C ause of Ignition
p ro v id e d e ta ile d d e s c rip tio n o f th e c a u s e o f ig n itio n - a ls o c h e c k b e lo w a s a p p lic a b le

 Intentional  Failure of equipment  Cause under investigation

> m is u s e o f h e a t s o u rc e , in c e n d ia ry fire > e q u ip m e n t n o t fu n c tio n in g p ro p e rly > o rig in a n d c a u se n o t y e t d e te rm in e d

 Unintentional  Act of nature  Cause undetermined

> c a re le s s , re c k le s s , a c c id e n ta l a c ts > w e a th e r, flo o d s , a n im a l b e h a v io u r > c a u s e u n d e te rm in e d a fte r in v e s tig a tio n

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 FIRE SAFETY REGULATIONS
F-15.11 REG 1 FIRE SAFETY
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E m ergency M anagem ent Basic Fire Incident Report

and Fire Safety P age 3 of 3

Factors Contributing to Ignition

p ro v id e d e ta ile d d e s crip tio n o f th e fa c to rs th a t a llo w e d h e a t s o u rc e a n d co m b u s tib le m a te ria ls to c o m e in to c o n ta c t/c o m b in e

 Misuse of materials  Design, Installation Deficiency  Fire spread or control

> u n s a fe u s e o r p la c e m e n t o f h e a t s o u rc e > d e s ig n , c o n s tru c tio n , in s ta lla tio n fa u lts > e x p o s u re , re k in d le , c o n tro lle d b u rn s

 Mechanical failure, malfunction  Operational Deficiency  Undetermined

> w o rn c o m p o n e n ts , c o n tro l fa ilu re , le a k > c o llis io n s , u n a tte n d e d e q u ip m e n t > ig n itio n fa c to rs c a n n o t b e d e te rm in e d

 Electrical failure, malfunction  Natural condition

> s h o rt c irc u it, a rc in g , e q u ip m e n t fa ilu re > w in d , flo o d , a n im a l b e h a v io u r

H um an F actors
p ro v id e d e ta ile d d e s c rip tio n o f th e h u m a n fa c to rs re la te d to th e fire - a ls o c h e c k b e lo w a s a p p lic a b le

 Asleep  Possible mentally disabled  None

> o c c u p a n t(s ) a s le e p a t tim e o f fire > p e rs o n s w ith p e rm a n e n t d is a b ilitie s > n o p e rs o n s in v o lv e d

 Impaired by alcohol or drugs  Physically disabled

> im p a ire d o c c u p a n t(s ) a s le e p o r a w a k e > p e rm a n e n t o r te m p o ra ry d is a b ilitie s

 Unattended  Multiple persons

> p e rs o n s re q u irin g c a re le ft u n a tte n d e d > n o te n u m b e r o f p e rs o n s a b o v e

Equipm ent Involved

in Ignition
p ro v id e d e ta ile d d e s c rip tio n o f e q u ip m e n t in v o lv e d in ig n itio n - a ls o c h e c k b e lo w a s a p p lic a b le

 Heating, ventilation, air conditioning  Commercial and medical equipment  Electronic, other electrical equipment
> fu rn a c e , fire p la c e , s to v e , w a te r h e a te r > v e n d in g m a c h in e s , O 2 e q u ip m e n t > c o m p u te rs , T V s , s te re o s , c a s h re g is te r

 Electrical distribution, lighting, power  Garden tools, agricultural equipment  Personal and household equipment
> d is trib u tio n p a n e ls , o u tle t, lig h ts > c o m b in e , c h a in s a w , m ilk in g m a c h in e > c lo th e s d ry e r, c u rlin g iro n , p o w e re d to y s

 Shop tools and industrial equipment  Kitchen and Cooking Equipment  Other equipment involved in ignition
> p o w e r s a w , w e ld in g to rc h , c o m p re s s o r > C o ffe e m a k e r, m ic ro w a v e , d is h w a s h e r > o th e r e q u ip m e n t n o t lis te d , n o n e

Brand or M ake Serial N um ber or other identification

M odel Ye ar of m anufacture

R em arks

P erso n C om pleting This R eport

N am e R ank/Title

Phone
W ork H om e C ell

R epresenting
g o v e rn m e n t a g e n c y , firm o r c o rp o ra tio n - p ro v id e a d d re s s

O ther F orm s filed with this R eport:  C asualty R eport  F ire D etector an d Extinguishing Equipm ent R eport

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APPROVED Septem ber 18, 2015 - 2:15 p.m .