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F15-11R1-AFire Incident Report PDF
F15-11R1-AFire Incident Report PDF
11 REG 1
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
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: $
Persons Involved
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
6
Property U se
Educational M ercantile / Business Storage
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
Building Status
Under Construction Under m ajor renovation Being dem olished
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
E M F S 0 3 /1 5 A -1
Not involved with ignition, but burned Freight road vehicle Industrial, agriculture, construction
Involved with ignition, but did not burn Transport vehicle M iscellaneous
M ake
M odel
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
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
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
E M F S 0 3 /1 5 A -2
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
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
M odel Ye ar of m anufacture
R em arks
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
E M F S 0 3 /1 5 A -3