Académique Documents
Professionnel Documents
Culture Documents
0 Self-Study Program
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
(a) True.
(b) False.
2. A Basic Module must be completed if the Fire Service Casualty Module is completed.
(a) True.
(b) False.
(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
he Fire Service Casualty Module is used to report fire service personnel injuries, deaths, or exposures 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.
DD
NFIRS5
YYYY
Delete
FDID
State
Incident Date
Station
Incident Number
Exposure
Change
Fire Service
Casualty
Injured Person
Casualty Number
Male
Career
1
1
The
of theNumber
Fire Module is drawn
from Section
A of theCBasic
Module. Use
B information in Section AIdentification
Female
Volunteer
2
2
the data in the Basic Module to help you supply the requested information. If you are using an autoCasualty Number
mated
system the data need
toLastbe
entered only once, then they will beSuffix
transferred automatically
into
First Name
Name
MI
other modules that use the data.
In years
G1
1
2
3
4
5
6
7
8
0
E
Date of Birth
OR
FDID
Month
Injured Person
Usual Assignment
B
G2
MM
DD
Date of Injury
YYYY
Midnight is 0000.
State
Day
Month
Day
Responses
Time of Injury
Station
Year
Incident Number
Hour
Minute
Delete
Number of prior responses
Exposure
during past 24 hours Change
NFIRS5
Fire Service
Casualty
Male
Career
1
Taken To
C Casualty Number
Not transported
Female
Volunteer
2
1
Hospital
0
Other
1
Rested
Suppression
4
Doctors office
Undetermined
U
2
Fatigued
Casualty Number
EMS First Name
5
Morgue/funeral
Last Name
Suffix home
Ill orMIinjured
4
Prevention
Residence
6
Training
Station or quarters
7
Severity
Midnight is 0000.
Responses
Maintenance
Age or DateG
of3Birth
Date and Time
ofOther
Injury
0
D
E
F
1
Report only, including exposure
Communications
2
First aid only
Date of Injury
Administration
Injury
Age
Date of Birth
Activity at TimeTime
of ofInjury
3
Treated by physician (no lost time)
G5
Fire investigation
OR4
Number of prior responses
Moderate (lost time)
Other
during past 24 hours
In years
Month
Day time) Year
Month
Day
Year
5
Severe
(lost
Hour
Minute
6
Life threatening (lost time)
Activity at time of injury
7
Death
Usual Assignment
Physical Condition Just Prior to Injury
Not transported
G1
G2
G4 Taken To
Physical Condition Just Prior to Injury
Identification Number
G
2 4
Section B is used to identify and classify the person injured or exposed using a variety of means.
Start completing Section B by entering an assigned identification number. While the individuals
Social Security Number often is used for this purpose, this is not a recommended practice.
Next, check the appropriate boxes indicating male or female, and the casualtys affiliation (career or
volunteer). Paid-per-call casualties should be considered volunteers when information for this sec1 Object
Hospital
tion isPrimary
entered.
Lastly,
enter the casualtys
firstCause
andoflast
middle initial, and
any
suffix (i.e.,None
Jr.,
Apparent
Symptom
Firefighter
Injury
Involved
0name,
Other
1
1
Suppression
H1
I1 Rested
I34 in Doctors
office
Injury
Undetermined
U
2
Fatigued
Sr., or III) in2 the lines
EMS provided.
5
Morgue/funeral home
3
Prevention
4
Training
5
Primary Part
of Maintenance
Body Injured
6
Communications
7
Administration
Primary injured8body part Fire investigation
0
Other
Ill or injured
Residence
6
Cause of injury
Station or quarters
7
Severity
None
G3 1 I2 Factor Contributing to Injury
Other
0
None
H2
Report only, including exposure
2
First aid only
Object involved in injury
Activity at Time of Injury
3
Treated
by physician (no lost time)
G5
Contributing factor
4
Moderate (lost time)
5
Severe (lost time)
Specific Location
Where
6
Where Injury Occurred
Life
threatening (lost time) Vehicle Type Activity at time of injuryComplete ONLY if
J3 Injury Occurred
J4
J1
Specific Location code
7
Death
is >60
1
En route to FD location
1
Suppression vehicle
65
In aircraft
2
2
At FD location
EMS vehicle
64Symptom
In boat, ship, or barge
Complete Cause of Firefighter
Primary
Apparent
Injury
Object Involved
3
Other
FD vehicle
3
En route to incident
scene
Block J4
Primary apparent symptom
5-4
None
DD
YYYY
NFIRS5
Incident Date
Station
Incident Number
Male
Female
1
2
Identification Number
Exposure
Career
Volunteer
1
2
Fire Service
Casualty
Change
Casualty Number
Casualty Number
Last Name
MI
Suffix
MM
DD
YYYY
Each casualty
is given a number.
The
numbers are
assigned
sequentially
starting with one (001), and
Midnight
is 0000.
Responses
Date and Time of Injury A
E
F
Incident Date
continuing based upon how manyFDIDfire serviceState
individuals
were injured orStation
killed atIncident
theNumber
incident, or Exposure
Date of Injury
Time of Injury
resulting from the incident.
ate of Birth
onth
Day
1
2
4
Rested
Fatigued
Ill or injured
Day
0
U
BHour
Year
1
2
A34
5
6
7
Identification Number
Not transported
MI
Hospital
Doctors office
Age or Date ofhome
Birth
Morgue/funeral
Residence
Age
Station
or quarters
Other
OR
In years
Identification Number
Month
Last Name
Cause of injury
OR
In years
Month
Year
Month
Day
Year
Midnight is 0000.
Month
Day
Year
Hour
Minute
Number
during pa
NFIRS5
1
4
5
6
7
0
None
Casualty Number
Suffix
2
First aid only
3
Treated by physician (no lost time)
Midnight is 0000.
Responses
4
Moderate (lost
F time)
5
Severe (lost time)
Time of Injury
6
Life threatening (lost time)
7
Death
Number of prior responses
Minute
Time of Injury
0
Other
1
Rested
Undetermined
U
2
Fatigued
Casualty
Number
Career
C
Ill or injured
4
Volunteer
Hour
Casua
Casualty
Fire Service
Physical
Condition
Prior to Injury
Exposure
not
both.
If the
ageChange
isJust
entered,
the numbers
are To
Casualty
G
2
G4 Taken
Day
Year
Delete
1
Suppression
Male
1
2
EMS 1
Female
2
2
3
Prevention
Object Involved
4
Training
I3 in Injury
5
Maintenance
G3
6
Communications
7
Administration
8
Fire investigation
None Date and Time of Injury
0 E Other
Date of Birth
Contributing factor
Day
Suffix
Severity
Section E: Date and Time
of Injury
1
Report only, including exposure
None
Age
Career
Volunteer
1
2
Date of Injury
Date of Birth
Male
Female
Last Name
Station
Incident Number
Enter either the casualtys age
dateAssignment
of birth,
but
G1orUsual
assumed to represent years.Activity at time of injury
First Name
1
2
Minute
First Name
1
4
5D
6
7
0
Other
Undetermined
I1
Injured Person
during past 24 hours
Section
D: Age or Date of Birth
Taken To
G4
Severity
om
ured
Month
G2
G3
Year
Delete
Change
G5
Not
Hospital
Doctors office
Morgue/funeral home
Residence
Station or quarters
Other
Activity at Time of Injury
Vehicle Type
Complete ONLY if
J4
Primary Apparent Symptom
Cause of Firefighter Injury
Object Inv
Specific Location code
H
1
I1
I3 in Injury
is >60
1
Physical Condition
Just Prior vehicle
to Injury
Suppression
Not transported
G651 In aircraft
G2
G4 Taken To
2
EMS vehicle
64 DD In boat,
ship, or barge
Complete
1
Cause of injury
Primary
apparent symptom
1
Hospital
3
YYYY
Other
FD
vehicle
e MM
0
Other
NFIRS5
1
Rested
Block J4
In
rail vehicle
Delete
163
Suppression
4
Doctors
4
Non-FD
vehicle
Undetermined
U Primary
2
Fatigued
ty
Noneoffice
Fire
Service
Factor
Contributing
to
Injury
Part
of
Body
Injured
61
In
motor
vehicle
EMS
None
Incident 2
Date
Station
Incident Number
5
Morgue/funeral
H2 Exposure
I2 home
Change
Ill or injured
4
Casualty
In
sewer
354
Prevention
Residence
6
Object involved in injur
In
tunnel
453
Training
Remarks
Station or quarters
7
Severity
49
In structure
Contributing factor
Primary
injured
body
part
5
Maintenance
G
3 Male
Other
0
Career
45
In attic
1
1 only,
1
Report
including exposure
00
Other
C Casualty Number
636
Communications
In
water
Identification
Number
FemaleFirst aid
Volunteer
2
2 only
UU
Undetermined
2
ity 735
Administration
Specific
Location
Where
Activity
at Time
of Injury
In
well
Vehicle Type
Where
Injury
Occurred
C
3
Treated by physician
(no
lost time)
G5 J3 Injury Occurred
J4
834
Fire
investigation
J1
S
In
ravine
4
Casualty Number
Moderate
(lost
time)
is
033
Other
In
quarry or mine
1Suffix En route to FD location
1
Suppression vehicle
Last Name
MI
5
Severe
(lost
time)
32
In ditch or trench
65
In
aircraft
2
2
At FD location
EMS vehicle
6
Life threatening (lost time)
In open pit
64
In boat, ship, or barge
Complete
ed 31
3
Other FD vehicle
3
En route to incident scene Activity at time of injury
Block J4
7
Death
28
On steep grade
63
In
rail
vehicle
Midnight is 0000.
Responses
4
Non-FD vehicle
and Time of Injury
4
En route to medical
facility
27
On fire escape/outside
stairs
61
In motor vehicle
E Date
F
5
At scene in structure
26
On vertical surface or ledge
54
In sewer
of Injury
of Injuryfailed and
If protective Time
equipment
of Birth25
On ground
ladderDate
53
In tunnel Object Involved
Primary
Apparent
Symptom
of Firefighter
6 this Cause
At scene
outside Injury
was a factor in
injury,
please
None Remarks
H241 On aerial ladder or in basket
I
1
I3 in Injury
49
In structure
complete the7other side
of this
At medical
facility
Number of prior responses
23
On roof
45
In
attic
form.
during past 24 hours
00
Other
h
Day
Year
Month
Day
Year
8
Returning
from
incident
Hour
Minute
22
Outside at grade
36
In water
NFIRS5 Revision 01/01/05
UU
Undetermined
of injury
Primary apparent symptom
9 Cause
Returning
from med facility
35
In well
0
Other
None
34
In
ravine
Factor Contributing to Injury
Primary Part of Body Injured
I2U ToUndetermined Not transported 33 NoneIn quarry or mine
G2 H2Physical Condition Just Prior to Injury G4 Taken
J3
Enter the date and time of the injury in Section E. When the injury date is the same as the date of the
incident, enter the same date information that you entered in the arrival block of Section E of the
Basic Module. If the injury date is different, then enter the correct month, day, and year.
The time, both hours and minutes, of the injury is entered using the 24-hour clock, where midnight is 0000.
Section F: Responses
1
2
4
Record the number of incidents that the casualty responded to within the 24-hour period immediObjector
involved
in injury
32
In ditch
trench
ately prior to the time of injury.
1
Hospital
0
Other
Rested
In open pit
Story Where
Injury Occurred 31
Contributing
factor
Primary injured body part
4
Doctors
office
J2
28
On steep grade
Undetermined
U
Fatigued
5
Morgue/funeral home
27
On fire escape/outside stairs
Ill or injured
Check this box and enter the story if the
1 Residence
6
26TypeOn vertical surface or ledge
Specific
Location
Where
injury occurred inside or on a structure Vehicle
Where Injury Occurred
Complete ONLY if
J
3
25
On ground ladder Specific Location code
JSeverity
1
Station or quarters J4
7
Injury Occurred
Story of injury
Below grade
is >60
G3 11 En route to FD location
24
On aerial ladder or in
basket
Other
0
1
Suppression vehicle
Report only, including exposure
23
On roof
65
In aircraft
2
2
At
FD
location
EMS
vehicle
2
First aid only
22
Outside at grade
Injury
outside
64
In boat, ship,
2or barge
Activity
atoccurred
Time
of Injury
Complete
3
Other FD vehicle
En
route by
to incident
scene
33
Treated
physician
(no lost time)
Block J4
G5vehicle
63
In rail
4
Non-FD vehicle
En
route to(lost
medical
44
Moderate
time)facility
5-5
61
In motor vehicle
NFIR
Injured Person
First Name
NFIRS
5.0 Self-Study Program
1
2
Identification Number
MI
Male
Female
1
2
Last Name
Suffix
State
Injured Person
A
B
FDID
State
First Name
Injured Person
Date of Birth
In years
Month
Date of Injury
Day
Year
Month
Day
Year
Midnight is 0000.
Time of Injury
Hour
DD
G1
YYYY
Usual
Assignment
G2
Describe theAgeofficial assignment of the casualty in Block G1. This may or may not coincide with the
OR
Number of prior responses
firefighters activity
at the
timeMonth
of injury.
during past
24 hours
Midnight is 0000.
In years
Responses
Day
Year
MonthDate
Day
Year
Hour
Minute
Primary
Apparent
Symptom
Cause of Firefighter
Injury
and Time
of Injury
D Age or Date of Birth
E
F
H1
I1
First Name
Age
Usual Assignment
G1
OR
In years
Minu
Age
Career
Volunteer
Date of Birth
G2
Month
1
2
4
Date of Injury
PhysicalPrimary
Condition
Just Prior to Injury
apparent symptom
G4
Day
Part
of Body
Injured Year
0 Month
Other
HRested
2
Undetermined
U
Fatigued
Ill or injured
PhysicalPrimary
Condition
Just Prior to Injury
injured body part
Day
Time of Injury
Year
Primary
Taken To
Cause of injury
Not oftransported
Number
prior responses
I2
4
Doctors
office
O
5
Morgue/funeral home
To Contributing factor Not transported
G4 67TakenResidence
Station or quarters
Severity
1
Hospital
0 DeleteOtherNFIRS5
1
Rested
Other
0
2
1
Report
only,
including
exposure
Specific
Location
Where
Vehicle Type
4
Doctors
office
Where Injury
Fire Service
Undetermined
U Occurred
2
Fatigued
J3 Injury 5Occurred
J4
J
1First
2
aid only
Exposure
Morgue/funeral
home
Change
Ill or injured
4
Casualty
Activity at Time of Injury
3
by physician
(no lost time)
1 Treated
En route
to FD location
1
G5 6
Residence
Suppressio
65
In aircraft
4 Severity
(lost time)
2
2 Moderate
At FD location
Station or quarters
7
EMS vehic
In boat, ship,
or barge
Complete
5
(lost to
time)
3
Casualty
Number64
Other
Other FD v
0
Career
3 Severe
En
route
incident
scene
11
Block
J4
Report
only, C
including
exposure 63
In rail vehicle
6
LifeEn
threatening
(lost time)
4
Non-FD ve
Volunteer
4 First
22
route
to medical
facility
Activity atvehicle
time of injury
61
In
motor
aid
only
7
Death
Activity at Time of Injury
5 Treated
At scene
in structure
3
by physician
(no lost time)54 GIn5 sewer
53
In tunnel
6 Moderate
At scene
outside
Casualty Number
4
(lost
time)
Remarks
49
In structure
7Suffix
At medical
facility
5
Severe
(lost time)
Cause of Firefighter
Injury
Object Involved
None
45
In
attic
I1 from
00 I3 Other
6
threatening
(lost
time)
8 LifeReturning
incident
in Injury
Activity at time of injury
36
In water
UU
Undetermined
7
Death
Midnight
is 0000.
9
Returning
from
med
facility
Responses 35
In well
E Date and Time of Injury 0 Other
F
Cause of injury
Primary apparent symptom
34
In ravine
U of Injury
Undetermined
33
In quarry or mine
Date of Injury
Time
None
Factor
Contributing
to
Injury
Primary Apparent
Part of Body
Injured
Symptom
Cause of Firefighter Injury
Object Involved
In ditch or trench
None
None
I12 Number of prior responses 32
I3 in Injury
31
In open pit
Story Where Injury
Occurred
Object
involved
in
injury
during past 24 hours
JHour2 Minute
28
On steep grade
Month
Day
Year
1
Suppression
2
EMS
3
Prevention
Assignment
G41 Usual
G2
Training
MM
DD
YYYY
5
Maintenance
G3
1
Suppression
6
Communications
2
EMS
Incident Date
Station
Incident
Number
7
Administration
3
Prevention
8
Fire investigation
4
Training
0
Other
5
Maintenance
Male G3
1
6
Communications
Identification Number
Female
2
7
Administration
8
Fire investigation
0
Other
Last Name
MI
Primary Apparent Symptom
H1
None
Record the general physical condition of the casualty just prior to the injury in Block G .
State
son
of Birth
Date of Birth
OR
Month
DescribeHthe
severity or seriousness of the casualty in relation to death and time lost from work in
2
1
Block Year
G3.
Day
27
On fire escape/outside stairs
26
On vertical surface or ledge
If protective equipment failed
None
Factor Contributing
Primary
Part of
25to Injury
On groundNone
ladder
nment
Physical Condition
Just Prior
to Body
InjuryInjured
was a factor in this injury, ple
2
2
Story of injuryWhere
To Location
Specific
Below
grade
Vehicle
Type or in basket
Not
transported
2
4 3Taken
Where Injury Occurred
24
On
aerial ladder
Complete complete
ONLY if
the other side of th
4
1
Object involved in injury
Specific
Location
Injury
Occurred
23
On roof
form. code
Hospital
1
is >60
0
Other
1
Rested1
En
route
tobody
FDpart
location
22
Outside
at grade
1
ion
Suppression
vehicle
Contributing factor
Primary
injured
Injury occurred
outside
office
4 2 Doctors
Undetermined
U
2
Fatigued
65
In aircraft
2
2
At FD location
EMS vehicle
Morgue/funeral
home
5
Ill or injured
4
64
In
boat,
ship,
or
barge
Complete
3
n
Other FD vehicle
3
En route to incident scene
Location Where Block J4
636 Specific
InResidence
rail vehicle
Type vehicle
Where Injury Occurred
Complete ONLY if
4Vehicle
Non-FD
3
4 1 En route to medical facility
or
quarters
4
Severity
617 Injury
InStation
motor
vehicle
Specific Location code
Occurred
nce
3
is >60
5
At
scene
in
structure
Other
0
54
In sewer
route toexposure
FD location
1
Suppression vehicle
1
Report1only,En
including
cations
53
tunnel
6
At
scene
outside
65
In
aircraft
2
2
At
FD
location
EMS
vehicle
Remarks
2
First aid only
ation
49 Activity
structure
atship,
Timeorofbarge
Injury Complete
64
In boat,
7 by physician
At medical
facility
3
Other FD vehicle
3
3
En
route to
incident
scene
Treated
(no
lost time)
5 63
Block J4
tigation
45
atticvehicle 00
In
rail
Other
4
8 (lost
Returning
incident
4
Non-FD vehicle
4
Moderate
time) tofrom
4
En
route
medical
facility
36
water vehicleUU
61
In motor
Undetermined
9(lostAt
Returning
med facility
5
Severe5
time)
35
well
scene infrom
structure
54
In sewer
0
Other
6
Life threatening
(lost outside
time)
34
ravine
53
tunnel
6
At
scene
Activity atIn
time
of injury
Remarks
Undetermined
33
quarry or mine
7
Death 7U
49
In structure
At medical facility
32
ditch or trench
45
In attic
00
Other
8
Returning from incident
31
open pit
In water
Story Where Injury Occurred 36
UU
Undetermined
9 2 Returning
med facility
28
Onwell
steep gradeObject Involved
In
parent Symptom
Cause from
of Firefighter
Injury 35
None
0
1Other
3 in Injurystairs
27
Onravine
fire escape/outside
34
In
this box and enter the story if the
1U Check
26
On
vertical
surface
or
ledge
Undetermined
33
In
quarry
or
mine
injury occurred inside or on a structure
If protective equipment failed and
25
Onditch
ground
ladder
32
In
or trench
was a factor in this injury, please
Cause
injury
ymptom
Story ofofinjury
Below grade
24
Onopen
aerialpitladder or in basket
31
In
complete the other side of this
Story Where Injury Occurred
23
On
roof
form.
None
2
28
steep grade
Factor Contributing to Injury
t of Body Injured
None at grade
2
22
Outside
27
On fire escape/outside stairs
Injury occurred outside
NFIRS5 Revision 01/01/05
2
Check this box and enter the story if the
1
26
On vertical
surface
ledge
Object
involvedor
in injury
injury occurred inside or on a structure
If protective equipment failed and
25
On ground ladder
was a factor in this injury, please
Contributing
factor Below grade
y part
Story of injury
24
On aerial ladder or in basket
complete the other side of this
23
On roof
form.
22
Outside
Injury occurred
outside
Specific Location
Where
NFIRS5 Revision 01/01/05
Vehicle
Type at grade
2
Occurred
Primary apparent
injured body
part
Primary
symptom
H
J
GJ
Contributing
factor
Cause of injury
Check this box and enter the story if the
injury occurred inside or on a structure
5-6
J3
Injury Occurred
J4
Complete ONLY if
Specific Location code
nment
1
2
4
on
ce
ations
tion
igation
G2
G3
arent Symptom
mptom
of Body Injured
Rested
Fatigued
Ill or injured
0
U
Other
Undetermined
Severity
1
2
3
4
5
6
7
G4
A
Taken To
NotMM
transported
DD
YYYY
1
Hospital
Incident Date
4FDID Doctors office
State
5
Morgue/funeral home
Residence
6 NFIRS
5.0 Self-Study Program
Station
7
Injured
Personor quarters
Other
0
Identification Number
GName
5
AFirst
FDID
DD
Age
Male
Female
1
2
Exposure
Career
Volunteer
1
2
Suffix
Exposure
Incident Number
Career
Time of Injury
Volunteer
Use Block G5 to
describe
whatInjury
type of activityORwas
taking
place atNone
the time the injury occurred.
Cause
of Firefighter
Object
Involved
I1
I3 in Injury
In years
Month
Day
Year
Month
Day
Year
Hour
Minute
First Name
Last Name
MI
You will need to enter a code as
part of the description.
Use
the NFIRS Complete Reference Guide (CRG)Suffix
of injury
to identify theCause
activity
of the firefighter
at the time of the injury.
Usual Assignment
Just Prior to Injury
Midnight is 0000.
None
To
Factor Contributing to
Injury
Date and Time of Injury
G
1 Age or Date
G2 Physical Condition E
G4 Taken
None of Birth
D
I2
Rested
Fatigued
Ill or injured
Ca
0 Date ofOther
Injury
Undetermined
U
Cha
Midnight is 0000.
in injury 1
Age SuppressionObject involvedDate
of Birth
Cha
Casu
Dele
Station
D
B
Incident Number
YYYY
Last Name
MI
Incident Date
State
Dele
Station
1
4
5
6
7
0
FCas
Num
durin
Casu
Hospital
Time of Injury
Doctors office
Morgue/funeral Num
ho
durin
HourResidence
Minute
Station or quarters
Other
1
2
2
EMS
OR
4
3 In years
Prevention
Month
Day
Year
Month
Day
Year
4
Training
Specific Location Where
Severity
Vehicle Type
Occurred
Complete ONLY if
J3 Injury Occurred
5
Maintenance
G
3
J4
Specific Location code
1
Report only, including exposure
is >60 Physical
6
Communications
Assignmentvehicle
Condition Just Prior to Injury
D location
1 Usual
Suppression
To
2
First aid only
G
1
G
2
G4 Taken
7
Administration
Activity at Time of InjuN
65
In
aircraft
2
n
EMS vehicle
3
Treated
by physician (no lost time)
G
5
8
Fire
investigation
1
Hospital
64
In boat, ship, or barge
Complete
Rested
3 Suppression
Other FD vehicle
cident scene
41
Moderate (lost 0time) Other
1
Block J4
0
Other
63
In rail vehicle
4
Doctors office
Undetermined
U
Fatigued
Non-FD vehicle
52
edical facility
Severe (lost time)
1
2 4 EMS
61
In motor vehicle
5
Morgue/funeral ho
Ill
orthreatening
injured
4
6
Life
(lost
time)
ructure
3
Prevention
54
In sewer
Activity
of injury
Residence
6 at time
7
Death
53
In tunnel
4
Training
ide
Station or quarters
7
Remarks
Severity
49
In structure
5
Maintenance
G3 1
cility
Other
0
Report only, including exposure
45
In attic
6
Communications
00
Other
m incident
36
In water
2
First
aid
only
Primary
Apparent
Symptom
Cause
of
Firefighter
Injury
Object
UU
Undetermined
Activity at Time
Injur
m med facility
H781 Administration
I3 inofInjur
35
In well
3
Treated byI1physician (no lost
time)
MM
DD
YYYY
G
5
NFIRS5
Fire investigation
Delete
A 34 In ravine
4
Moderate
(lost
time)
0
Other
Fire Service
d
33FDID In quarry or State
mine
Incident Date
Incident Number
Exposure (lost time)
5
Severe
Cause
of injury
PrimaryStation
apparent symptom
Change
Casualty
32
In ditch or trench
6
Life threatening (lost time)
Activity at time of injury
None
In open pit
Factor Contributing to Injury
Primary Part of Body Injured 7
njury Occurred 31
None
Death
H2
I2
28
On steep grade
Injured
Casualty Number
Male
Career
1
1
27
OnPerson
fire escape/outside stairs
Object involved in
C
er the story if the B
26
On vertical surface or ledgeIdentification Number
Volunteer
2 part Female
2
r on a structure
Contributing factor
Primary
injured
body
If protective
equipment
failed
and
Primary Apparent Symptom
Cause of Firefighter Injury
Object
25
On ground ladder
was
H1a factor in this injury, please
I1
I3 in Injur
Below grade
24
On aerial ladder or in basket
complete the other side of this
Casualty Number
23
On roof
form.
Specific
Location Where
First Name
Last Name
Vehicle Type
MI
Suffix
Where Injury Occurred
J3 Injury
22
Outside at grade
J4
J1 Primary apparent symptom
NFIRS5 Revision
01/01/05
Occurred Cause of injury
1
En
route Part
to FDoflocation
1
Suppression vehicle
None
Primary
Body Injured
FactorResponses
Contributing to Injury
Midnight is 0000.
None
In aircraft I2
H
Date and Time of Injury65
2
2 2 At FD
EMS vehicle
D Age or Date of Birth
E location
F
64
In boat, ship, or barge
Complete
Object involved in
3
Other
FD vehicle
3
En route to incident scene
Block J4
63 TimeInofrail
vehicle
Date of Injury
Injury
Age
Date of Birth
4
Non-FD vehicle
4
En
route
tobody
medical
facility
Primary
injured
part
61
In motor vehicle Contributing factor
5
At scene in structure
54
In sewer
OR
Number of prior responses
during past 24 hours
In years
53 HourIn tunnel
Month
Day
Year 6
Month outside
Day
Year
At scene
Minute
Remarks
Specific
Location
Where
Vehicle Type
Where Injury Occurred
In structure
2
J493 Injury
7
J4
J1 At medical facility
Occurred
45
In attic
00
Other
8
Returning
incident
1
En
routePrior
tofrom
FD
1
Suppression vehicle
36
In water
Just
tolocation
Injury
UU
Undetermined
In
aircraft
9
Returning
from med facility
Not transported
G1 Usual Assignment
G2 Physical Condition
G4 65
2
2
At
FD location
EMS vehicle
35Taken
InTo
well
64
In
boat,
Complete
0
Other
34
In
ravineship, or barge
3
Other FD vehicle
En
to incident scene
1
Hospital
Block J4
0routeOther
1
Rested 3U
63
In
rail
vehicle
Undetermined
33
In
quarry oroffice
mine
1
Suppression
4
Non-FD vehicle
4
4
Doctors
En
to medical facility
UrouteUndetermined
2
Fatigued
61
In
motor
vehicle
32
In ditch or trench
2
EMS
5
Morgue/funeral
home
5
At scene in structure
54
In
sewer
Ill or injured
4
31
In open pit
3
Prevention
Where
Injury Occurred 53
Residence
6
In
6J2 Story
At scene
outside
28
Ontunnel
steep grade
Remarks
4
Training
49
In
structure
Station
or quarters stairs
7
Severity
7
At medical facility
27
On
fire escape/outside
5
Maintenance
Check
this
box
and
enter
the
story
if
the
G3 1
45
In
attic
Other
0
1
26
On vertical surface
00 or ledge
Other
Returning
from
occurred inside
or onincident
a structure
Report 8only,injury
including
exposure
6
Communications
If protective equipment failed and
36
In
25
Onwater
ground ladder
UU
Undetermined
from med
facility
2
First aid9 onlyReturning
was a factor in this injury, please
Story of injury
35
In
well
Below grade
7
Administration
at Time
of or
Injury
24 Activity
On aerial
ladder
in basket
complete the other side of this
3
Other
Treated0by physician
(no lost time)
In
G5 34
8
Fire investigation
23
Onravine
roof
form.
4
Moderate
time)
U (lost
Undetermined
33
In
quarryatorgrade
mine
0
Other
22
Outside
Injury
occurred
outside
2
32
In
ditch
or
trench
5
Severe (lost time)
31
In open pit
6
Life threatening
time)
Story(lost
Where
Injury Occurred Activity
at time of injury
28
On steep grade
7
Death J2
Contributing factor
part
Record the primary symptom and areas of injury in Section H. Use Block H to enter the code that
describes the casualtys most serious injury.
The Emergency Medical Technician (EMT) or the person responsible for the prehospital emergency
care phase of treatment may provide you with a determination of what appears to be the casualtys
most serious injury.
Block H is used to record the body part or area that sustained the most serious injury. It should be
the part of the body affected by the primary apparent symptom.
In Section I, record the data that describes the factors that caused the injury. Use the CRG to complete
this section.
1
H1
I
2
H2
27
26
Cause
of Firefighter
Injury 25
Story of injury
Below grade
24
1
23
22
Injury occurred outside
Check this box and enter the story if the
injury occurred inside or on a structure
Cause of injury
None
Contributing factor
J1
1
2
3
En route to FD location
At FD location
En route to incident scene
J3
65
64
In aircraft
In boat, ship, or barge
5-7J4
Complete
Block J4
Vehicle Type
1
2
3
Suppression vehicle
EMS vehicle
Other FD vehicle
Complete ONLY if
Specific Location code
is >60
Month
G2
Day
Year
Month
Day
6Year
7
Life threatening
(lost time)during past 24 hours
Hour
Minute
Death
Injured Person
A
Taken To B
Not transported
FDID
State
Cause of
Firefighter
Injury
IHospital
1
1
NFIRS 5.0 Self-Study Program
4
Doctors office
First Name
5
Morgue/funeral
home
Cause of injury
Injured
Person
B
Residence
6
None
Factor
Contributing
to Injury
or quarters
7
IStation
2
Age
or
Date
of
Birth
Other
0
D
G4
MM
DD
YYYY
Number
Incident Identification
Date
Object
I3
Station
Involved
in Injury
Female
Incident
Number
Male
1
2
Career
Volunteer
Exposure
1
2
Male
Female
1
2
Career
Volunteer
None
Last Name
MI
1
2
Suffix
Identification Number
Primary Part of Body Injured
None
Severity
Midnight is 0000.
H2
E Date and Time of Injury
Object involved in injury
1
Report only, including exposure
First Name
Last Name
MI
Suffixof Injury
Date of Injury
Time
2
First
aidinjured
onlybody part
Age
Date of Birth
Contributing
factor
Primary
Activity at
Time of
Injury
3
Treated by physician (no lost time)
G5
OR
4
Moderate (lost time)
Midnight is 0000.
In
yearsor Date of Birth
MonthType Day
Year
Specific Location Where
Age
Date Day
and TimeYear
of Injury
Hour
Minute
Vehicle
Where(lost
Injury
Occurred
5
Complete
ONLY if
Severe
time)
D
EMonth
J
3
J
4
J
1
Specific Location code
Injury
Occurred
6
Life threatening (lost time)
is
>60
Activity at time of injury
Date of Injury
Time of Injury
Age
of Birth
En route to FD2 location
1 Date
Suppression
vehicle
7 1 Death
Usual Assignment 2
Physical Condition Just Prior to Injury
65
In aircraft
2
At FD location
EMS
vehicle
Taken
To
G1 Complete
G2
G4
OR
64
In boat, ship, or barge
3 Month
Other FD
3
En route to incident scene
In years
Day vehicle
Year
Month
Day
Year
Block J4
Hour Hospital
Minute
1
63
In rail vehicle
0
Other
1 vehicle
Rested
mptom
Cause facility
of Firefighter
Object
Involved 4 NoneNon-FD
4
En route to medical
1
Suppression
61 Injury
In motor vehicle
4
Doctors o
I
1
I
3 in Injury
Undetermined
U
2
Fatigued
5
At scene in structure
2
EMS
54
In sewer
5
Morgue/fu
Ill or Condition
injured Just Prior to Injury
4 Physical
Usual
Assignment
3
Prevention
53
In tunnel
6
At scene outside
6TakenResidenc
To
Remarks G2
G
1
G
4
Cause of injury
49
In structure
4
Training
7
At medical facility
Station or
7
Severity
1
Hospital
45
In attic
Maintenance
0
Other
Rested
G3 11
00 5 Other
None
Other
8
0
Returning from
incident
Factor
Contributing to Injury
njured
Suppression
Report only, including
exposure
4
Doctors o
I2 from med facility 36 In water NoneUU 126 Undetermined
Communications
Undetermined
U
2
Fatigued
9
Returning
EMS
35
In well
2
First
aid
only
5
Morgue/fu
7Object involved
Administration
Ill or injured
4
in injury
Activity at Tim
0
Other
3
Prevention
34
In ravine
3
Treated by physician (no lost time)
Residence
G5 6
8
Fire investigation
U
UndeterminedContributing factor
33
In quarry or mine 4
Training
4
Moderate (lost time)
Station or
7
Severity
0
Other
32
In ditch or trench 5
Maintenance
G3 15
Severe (lost time)
Other
0
31
In
open
pit
Report
only,
including
exposure
3
6
Communications
StoryLocation
Where Injury
Occurred
6
Life threatening (lost time)
Specific
Where
Vehicle
Type
Activity at time of injury
J
2
28
On
steep
grade
Complete
ONLY
if
2
First
aid
only
J3 Injury Occurred
7
Administration
J4 On fire escape/outside
7
Death
Activity at Tim
Specific Location code
27
stairs
3
Treated by physician (no lost time)
G5
is >60
8
Fire investigation
Check this box and enter the story if the
1
1
26
On
vertical
surface
or
ledge
Suppression
vehicle
injury occurred inside or on a structure
4
Moderate (lost time)
0
Other
If protective equipment failed and
65
In aircraft
25
On2 ground
ladder
EMS
vehicle
5 please
Severe (lost time)
was a factor in this injury,
of injury
64
In boat,Story
ship,
or bargeBelow grade
Primary
Apparent
Symptom
Cause of Firefighter Injury
Complete
24
On
aerial
ladder
or
in
basket
3
Other FDH
vehicle
complete the other side
ene
6 of thisLife threatening
1
I1 (lost time)
I3
Block J4
63
In rail vehicle
Activity at time of injury
23
On4 roof Non-FD vehicle
form.
ility
7
Death
61
InInjury
motor
vehicle
22
Outside
at
grade
occurred outside
NFIRS5 Revision 01/01/05
2
G3
t
cility
urred
de
Enter the code and description for the most significant factor contributing to the casualtys injury in
Block I .
Then enter the code and description of the object that contributed to the injury in Block I .
54
53
49
45
36
35
34
33
32
31
28
27
26
25
24
23
22
In sewer
In tunnel
In structure
In attic
00
Other
In water
UU
Undetermined
In well
In ravine
In quarry or mine
In ditch or trench
In open pit
On steep grade
On fire escape/outside stairs
On vertical surface or ledge
On ground ladder
On aerial ladder or in basket
On roof
Outside at grade
Cause of injury
Remarks
H
H12
None
Primary
Symptom
Primary Apparent
Part of Body
Injured
II12
Cause
Firefighter Injury
Factor of
Contributing
to Injury
En
route
FDpartlocation
1
Primary
injuredto
body
At FD location
2
If protective equipment failed
3 andEn route to incident scene
was a factor in this injury, pleaseWhere Injury Occurred
4this
1 En route to medical facility
complete the other side ofJ
form.
At scene
in FD
structure
15
En
route to
location
NFIRS5
Revision 01/01/05
At FD
scene
outside
26
At
location
At medical
37
En
route to facility
incident scene
Returning
incident
48
En
route tofrom
medical
facility
Returning
med facility
59
At
scene infrom
structure
Other
60
At
scene outside
Undetermined
7U
At
medical facility
8
9J2
0
1
U
J2
J3
65
64
63
3
61
54
65
53
64
49
63
45
61
36
54
35
53
34
49
33
45
32
36
31
35
28
34
27
33
26
32
25
31
24
28
23
27
22
26
25
24
23
22
2
1
Below grade
Below grade
Obj
None
Factor Contributing to Injury
None
I2 Where
Specific Location
Vehicle Type
J
4
Obje
Injury Occurred
Contributing factor
1
Suppression
In aircraft
2
EMS vehicle
In boat, ship, or barge
Complete
3
Other FD veh
Specific
Location Where Block J4
Vehicle Type
In rail vehicle
Non-FD vehi
J4 4
Injury Occurred
In motor vehicle
In sewer
In
In aircraft
tunnel
In
ship, or barge
In boat,
structure
Complete
Block J4
In
In rail
atticvehicle 00
Other
In
In motor
water vehicleUU
Undetermined
In
In sewer
well
In
In tunnel
ravine
In
In structure
quarry or mine
In
In attic
ditch or trench
00
Other
In
In water
open pit
UU
Undetermined
In
Onwell
steep grade
In
Onravine
fire escape/outside stairs
In
or surface
mine or ledge
Onquarry
vertical
In
or trench
Onditch
ground
ladder
In
pitladder or in basket
Onopen
aerial
On
On steep
roof grade
On
fire escape/outside
stairs
Outside
at grade
On vertical surface or ledge
On ground ladder
On aerial ladder or in basket
On roof
Outside at grade
1
2
Remarks
3
4
5-8
Suppression
EMS vehicle
Other FD veh
Non-FD vehic
Remarks
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.
I3
Cause
of injury
Contributing
factor
Primary
symptom
Primaryapparent
injured body
part
H2
J1
None
rson
Identification Number
Last Name
MI
H2
1
2
Primary apparent symptom
Male
Female
Career
Volunteer
1
2
OR
gnment
sion
on
nce
ications
ration
stigation
J3
Where Date
Injury
Occurred
of Injury
En route to FD location
Month
Day
Year
At FD location
3
En route to incident scene
4
En route to medical facility
Just Prior to Injury
At scene in structure
G2 Physical 5Condition
6
At scene outside
0
Other
1
Rested
7
At medical
facility
Undetermined
U
2
Fatigued
Returning from incident
Ill or 8injured
4
9
Returning from med facility
Other
Severity 0
G3 1
U only,
Undetermined
Report
including exposure
parent Symptom
2
3
4
5
6
7
rt of Body Injured
Responses
Specific
Location Where
Time of Injury
Injury Occurred
Vehicle Type
J4
Suppression vehicle
Complete ONLY if
Specific Location code
is >60
Object Involved
in Injury
I1
I3
Block J3 is used to identify the casualtys specific location at the time of the injury.
None
Cause of injury
symptom
Note None
the codes Factor
by theContributing
specific location
If you selected a vehicle code greater than 60,
to Injury descriptions.
None
I2
also select the vehicle type in J4.
Object involved in injury
Contributing factor
ody part
y Occurred
FD location
on
incident scene
medical facility
structure
tside
facility
rom incident
rom med facility
ed
Injury Occurred
de
Midnight is 0000.
Year
2
Day
None
Contributing factor
Month
Casualty Number
I2
NFIRS 5.0 Self-Study Program
Suffix
e of Birth
J1
Casualty Number
Cause of injury
None
Date of Birth
Below grade
J3
65
64
63
61
54
53
49
45
36
35
34
33
32
31
28
27
26
25
24
23
22
J4
In aircraft
In boat, ship, or barge
Complete
Block J4
In rail vehicle
In motor vehicle
In sewer
In tunnel
In structure
4
In attic
00
Other
In water
UU
Undetermined
In well
In ravine
In quarry or mine
In ditch or trench
In open pit
On steep grade
On fire escape/outside stairs
On vertical surface or ledge
On ground ladder
On aerial ladder or in basket
On roof
Outside at grade
Vehicle Type
1
2
3
4
Complete ONLY if
Specific Location code
is >60
Suppression vehicle
EMS vehicle
Other FD vehicle
Non-FD vehicle
K1
Yes
Please complete the remainder of this form ONLY if you answer YES.
No
Equipment
Sequence
Number
NFIRS5
Fire Service
Casualty
Helmet
Full face protector
Partial face protector
Goggles/eye protection
Hood
Ear protector
Neck protector
Other
21
22
23
24
25
26
27
28
20
Protective coat
Protective trousers
Uniform shirt
Uniform T-shirt
Uniform trousers
Uniform coat or jacket
Coveralls
Apron or gown
Other
5-9
Boots or Shoes
31
12
Melted
21
22
Punctured
23
Scratched
24
Knocked off
25
Cut or ripped
K1
K2
Yes
Please complete the remainder of this form ONLY if you answer YES.
No
K3
11
12
13
14
15
16
17
10
21
22
23
24
25
26
27
28
20
NFIRS5
Equipment
Sequence
Number
Fire Service
Casualty
11
Burned
12
Melted
21
22
Punctured
23
Scratched
24
Knocked off
25
Cut or ripped
31
32
Insufficient insulation
33
41
42
43
44
45
46
47
48
49
51
52
Special Equipment
53
61
62
63
64
65
66
67
68
69
71
72
73
74
75
76
77
78
79
70
00
94
95
96
97
00
Helmet
Full face protector
Partial face protector
Goggles/eye protection
Hood
Ear protector
Neck protector
Other
Protective coat
Protective trousers
Uniform shirt
Uniform T-shirt
Uniform trousers
Uniform coat or jacket
Coveralls
Apron or gown
Other
Boots or Shoes
31
32
33
34
35
36
37
38
30
Respiratory Protection
41
42
43
44
45
46
40
Hand Protection
51
52
53
54
55
50
UU
K4
Undetermined
Equipment Manufacturer, Model and Serial
Number
Manufacturer
Model
Serial Number
Block K2 is used to record the protective equipment item that failed and was a factor in the casualtys
injury.
The choices are grouped into the following categories:
Respiratory Protection
Hand Protection
Special Equipment
5-10
NFIRS5
Revision 05/01/03
Yes
No
tem
or
tion
K3
Coat, Shirt, or Trousers
Protective coat
Protective trousers
Uniform shirt
Uniform T-shirt
Uniform trousers
Uniform coat or jacket
Coveralls
Apron or gown
Other
21
22
23
24
25
26
27
28
20
NFIRS5
Equipment
Sequence
NFIRS
5.0 Self-Study Program Fire Service
Number
Casualty
11
Burned
12
Melted
21
22
Punctured
23
Scratched
24
Knocked off
25
Cut or ripped
31
32
Insufficient insulation
33
41
42
43
en circuit
ssure) open circuit
t
44
45
r
sk
46
47
48
49
51
52
53
94
95
96
97
00
UU
Undetermined
with wristlets
without wristlets
ntry
on-entry
ed, reusable chemical suit
ed, disposable chemical suit
ted, reusable chemical suit
ted, disposable chemical suit
uit
belt
Was the failure of more
y system (PASS)
3 toitem
Use
record
the most
thanKone
of protective
ce
equipment a factor in the
other
ent, other
uted
to the injury.
injury? If so, complete an
additional page of this
form for each piece of
failed equipment.
K4
significant Manufacturer
problem with the piece of equipment that failed and contribModel
Serial Number
5-11
NFIRS5
Revision 05/01/03
uit
ed underwater breathing apparatus (SCUBA)
er
ladder belt
Was the failure of more
ert safety system (PASS)
than one item of protective
ess device
equipment a factor in the
hting
injury? If so, complete an
or tent
additional page of this
ety belt
form for each piece of
failed equipment.
ipment, other
quipment, other
95
96
97
00
UU
Undetermined
K4
Model
Serial Number
NFIRS5
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 manufacturers 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 manufacturers serial
number, usually stamped on the equipments 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.
5-12
5-13
5-14
K1
K2
Yes
Please complete the remainder of this form ONLY if you answer YES.
No
K3
11
12
13
14
15
16
17
10
21
22
23
24
25
26
27
28
20
NFIRS5
Equipment
Sequence
Number
Fire Service
Casualty
11
Burned
12
Melted
21
22
Punctured
23
Scratched
24
Knocked off
25
Cut or ripped
31
32
Insufficient insulation
33
41
42
43
44
45
46
47
48
49
51
52
Special Equipment
53
61
62
63
64
65
66
67
68
69
71
72
73
74
75
76
77
78
79
70
00
94
95
96
97
00
UU
Undetermined
Helmet
Full face protector
Partial face protector
Goggles/eye protection
Hood
Ear protector
Neck protector
Other
Protective coat
Protective trousers
Uniform shirt
Uniform T-shirt
Uniform trousers
Uniform coat or jacket
Coveralls
Apron or gown
Other
Boots or Shoes
31
32
33
34
35
36
37
38
30
Respiratory Protection
41
42
43
44
45
46
40
Hand Protection
51
52
53
54
55
50
5-15
K4
Model
Serial Number
NFIRS5
Revision 05/01/03
5-16
NFIRS5
YYYY
Delete
FDID
DD
Incident Date
State
Station
Incident Number
Injured Person
1
2
Identification Number
Male
Female
Exposure
Change
Career
Volunteer
1
2
Fire Service
Casualty
Casualty Number
Casualty Number
First Name
Last Name
MI
Suffix
Midnight is 0000.
Date of Injury
Date of Birth
Time of Injury
OR
In years
G1
1
2
3
4
5
6
7
8
0
H1
Month
Usual Assignment
Suppression
EMS
Prevention
Training
Maintenance
Communications
Administration
Fire investigation
Other
Day
Month
1
2
4
Rested
Fatigued
Ill or injured
Year
Hour
0
U
G4
Other
Undetermined
I1
Minute
Taken To
1
4
5
6
7
0
Severity
1
2
3
4
5
6
7
Not transported
Hospital
Doctors office
Morgue/funeral home
Residence
Station or quarters
Other
Activity at Time of Injury
G5
I3
Object Involved
in Injury
None
Cause of injury
H2
Day
G2
G3
Year
Responses
None
I2
None
Object involved in injury
Contributing factor
J1
1
2
3
4
5
6
7
8
9
0
U
En route to FD location
At FD location
En route to incident scene
En route to medical facility
At scene in structure
At scene outside
At medical facility
Returning from incident
Returning from med facility
Other
Undetermined
J2
Below grade
J3
65
64
63
61
54
53
49
45
36
35
34
33
32
31
28
27
26
25
24
23
22
5-17
J4
Vehicle Type
1
2
3
4
Suppression vehicle
EMS vehicle
Other FD vehicle
Non-FD vehicle
Complete ONLY if
Specific Location code
is >60
Remarks
K1
K2
Yes
Please complete the remainder of this form ONLY if you answer YES.
No
K3
11
12
13
14
15
16
17
10
21
22
23
24
25
26
27
28
20
NFIRS5
Equipment
Sequence
Number
Fire Service
Casualty
11
Burned
12
Melted
21
22
Punctured
23
Scratched
24
Knocked off
25
Cut or ripped
31
32
Insufficient insulation
33
41
42
43
44
45
46
47
48
49
51
52
Special Equipment
53
61
62
63
64
65
66
67
68
69
71
72
73
74
75
76
77
78
79
70
00
94
95
96
97
00
UU
Undetermined
Helmet
Full face protector
Partial face protector
Goggles/eye protection
Hood
Ear protector
Neck protector
Other
Protective coat
Protective trousers
Uniform shirt
Uniform T-shirt
Uniform trousers
Uniform coat or jacket
Coveralls
Apron or gown
Other
Boots or Shoes
31
32
33
34
35
36
37
38
30
Respiratory Protection
41
42
43
44
45
46
40
Hand Protection
51
52
53
54
55
50
5-18
K4
Model
Serial Number
NFIRS5
Revision 05/01/03
5-19
K1
K2
Yes
Please complete the remainder of this form ONLY if you answer YES.
No
K3
11
12
13
14
15
16
17
10
21
22
23
24
25
26
27
28
20
NFIRS5
Equipment
Sequence
Number
Fire Service
Casualty
11
Burned
12
Melted
21
22
Punctured
23
Scratched
24
Knocked off
25
Cut or ripped
31
32
Insufficient insulation
33
41
42
43
44
45
46
47
48
49
51
52
Special Equipment
53
61
62
63
64
65
66
67
68
69
71
72
73
74
75
76
77
78
79
70
00
94
95
96
97
00
UU
Undetermined
Helmet
Full face protector
Partial face protector
Goggles/eye protection
Hood
Ear protector
Neck protector
Other
Protective coat
Protective trousers
Uniform shirt
Uniform T-shirt
Uniform trousers
Uniform coat or jacket
Coveralls
Apron or gown
Other
Boots or Shoes
31
32
33
34
35
36
37
38
30
Respiratory Protection
41
42
43
44
45
46
40
Hand Protection
51
52
53
54
55
50
5-20
K4
Model
Serial Number
NFIRS5
Revision 05/01/03
5-21
Delete
Incident Date
State
Location Type
Station
Incident Number
Exposure
NFIRS1
Number/Milepost
Prefix
Basic
No Activity
Check this box to indicate that the address for this incident is provided on the Wildland Fire
Module in Section B, Alternative Location Specification." Use only for wildland fires.
Street address
Intersection
In front of
Rear of
Adjacent to
Directions
US National Grid
Census Tract
Street or Highway
Street Type
Suffix
Apt./Suite/Room
City
State
ZIP Code
Incident Type
E1
Incident Type
YYYY
Change
FDID
DD
None
Midnight is 0000
Month
Check boxes if
dates are the
same as Alarm
Date.
Day
Year
Hour
E2
Min
Shift or
Platoon
Alarm
Alarms
District
1
2
3
4
5
Their FDID
Last Unit
Cleared
G1
Resources
G2
Apparatus
Personnel
Suppression
Additional Action Taken (2)
H1
Casualties
None
Deaths Injuries
Fire
Service
Civilian
H2
1
2
U
Detector
Required for confined fires.
H3
1
2
3
4
5
6
7
8
0
Special
Study Value
LOSSES:
Property
Contents
None
EMS
Other
Additional Action Taken (3)
Special
Study ID#
Fire2
Structure Fire3
Local Option
Controlled
Actions Taken
Completed Modules
Special Studies
Their
State
E3
Arrival
Property
Contents
None
Mixed Use
Property
10
20
33
40
51
53
58
59
60
63
65
00
Not mixed
Assembly use
Education use
Medical use
Residential use
Row of stores
Enclosed mall
Business & residential
Office use
Industrial use
Military use
Farm use
Other mixed use
Property Use
None
Structures
Church, place of worship
131
Restaurant or cafeteria
161
Bar/tavern or nightclub
162
Elementary school, kindergarten
213
High school, junior high
215
College, adult education
241
Nursing home
311
Hospital
331
341
342
361
419
429
439
449
459
464
519
539
571
579
599
615
629
700
819
882
891
Outside
Playground or park
124
Crops or orchard
655
Forest (timberland)
669
Outdoor storage area
807
Dump or sanitary landfill
919
Open land or field
931
936
938
946
951
960
961
962
Vacant lot
Graded/cared for plot of land
Lake, river, stream
Railroad right-of-way
Other street
Highway/divided highway
Residential street/driveway
981
984
Construction site
Industrial plant yard
5-22
Property Use
Code
Property Use Description
NFIRS1 Revision 01/01/05
K1
Local Option
First Name
Number
Prefix
State
Area Code
MI
Phone Number
Last Name
Suffix
Street or Highway
Street Type
Apt./Suite/Room
Suffix
City
ZIP Code
More people involved? Check this box and attach Supplemental Forms (NFIRS1S) as necessary.
Owner
K2
Local Option
First Name
Number
MI
Prefix
State
Area Code
Phone Number
Last Name
Suffix
Street or Highway
Street Type
Apt./Suite/Room
Suffix
City
ZIP Code
Remarks:
Local Option
ITEMS WITH A
More remarks? Check this box and attach Supplemental Forms (NFIRS1S) as necessary.
Authorization
Check box if
same as
Officer in
charge.
Officer in charge ID
Signature
Position or rank
Assignment
Month
Day
Year
Signature
Position or rank
Assignment
Month
Day
Year
5-23
MM
FDID
DD
YYYY
Incident Date
State
Station
Property Details
B1
C
Not Residential
Incident Number
On-Site Materials
or Products
Change
Exposure
None
On-Site Materials
Storage Use
1
2
3
4
U
1
2
3
4
U
1
2
3
4
U
B3
None
D
D1
D2
Ignition
E1
Heat source
D3
Item first ignited
Cause of Ignition
Skip to
Section G
E3
Intentional
Unintentional
Failure of equipment or heat source
Act of nature
Cause under investigation
Cause undetermined after investigation
E2
3
4
5
None
6
Estimated age of
person involved
F1
F2
None
Asleep
Possibly impaired by
alcohol or drugs
Unattended person
Possibly mentally disabled
Physically disabled
Multiple persons involved
1
2
Human Factors
Contributing to Ignition
1
2
3
4
5
U
D4
Fire
B2
NFIRS2
Delete
Male
Female
None
Equipment Involved
F3
Brand
Model
Serial #
Equipment Portability
1
Portable
Stationary
Year
H1
None
H2
Local Use
Pre-Fire Plan Available
Some of the information presented in this report may be
based upon reports from other agencies:
Year
State
VIN
Structure fire? Please be sure to complete the Structure Fire form (NFIRS3).
NFIRS2 Revision 01/01/05
5-24
I1
1
2
3
4
5
6
7
8
0
Enclosed building
Portable/mobile structure
Open structure
Air-supported structure
Tent
Open platform (e.g., piers)
Underground structure (work areas)
Connective structure (e.g., fences)
Other type of structure
Fire Origin
J1
I2
Building Status
1
2
3
4
5
6
7
0
U
Under construction
Occupied & operating
Idle, not routinely used
Under major renovation
Vacant and secured
Vacant and unsecured
Being demolished
Other
Undetermined
J3
None Present
Present
Undetermined
Detector Type
1
2
3
4
5
0
U
Smoke
Heat
Combination smoke and heat
Sprinkler, water flow detection
More than one type present
Other
Undetermined
M1
1
2
3
4
5
6
7
0
U
0
U
L4
Detector Operation
Operated
Complete
Block L5
Failed to operate
Complete
Block L6
Undetermined
Wet-pipe sprinkler
Dry-pipe sprinkler
Other sprinkler system
Dry chemical system
Foam system
Halogen-type system
Carbon dioxide (CO2) system
Other special hazard system
Undetermined
Width in feet
K1
Skip to
Section L
M3
K2
Type of material contributing
most to flame spread
L5
Battery only
Hardwire only
Plug-in
Hardwire with battery
Plug-in with battery
Mechanical
Multiple detectors & power
supplies
Other
Undetermined
1
2
3
4
5
6
7
M2
BY
Length in feet
L3
Skip to
Section M
,
Total square feet
Fire Spread
NFIRS3
Structure
Fire
OR
Presence of Detectors
L2
Story of
fire origin
L1
I4
2
3
4
5
Building
Height
Below grade
J2
I3
1
2
3
4
U
L6
Detector Effectiveness
Required if detector operated.
1
2
3
4
5
6
0
U
Operation of Automatic
Extinguishing System
M5
1
2
3
4
0
U
M4
Number of Sprinkler
Heads Operating
1
2
3
4
5
6
7
8
0
U
5-25
Revision 01/01/06
DD
Delete
FDID
State
Incident Date
Station
Gender
1
Male
First Name
MI
E1
Date of Birth
Month
Day
Year
Race
0
U
Other, multiracial
Undetermined
Affiliation
1
2
3
0
E2
1
0
Date of Injury
Hispanic or Latino
Non Hispanic or Latino
Cause of Injury
Exposed to fire products including flame
heat, smoke, and gas
Exposed to toxic fumes other than smoke
Jumped in escape attempt
Fell, slipped, or tripped
Caught or trapped
Structural collapse
Struck by or contact with object
Overexertion or strain
Multiple causes
Other
Undetermined
M1
Midnight is 0000.
Time of Injury
Escaping
Rescue attempt
Fire control
Return to fire before control
Return to fire after control
Sleeping
Unable to act
Irrational act
Other
Undetermined
Month
Day
Year
Human Factors
Contributing to Injury
Hour
None
Severity
Minor
Moderate
Severe
Life threatening
Death
Undetermined
1
2
3
4
5
U
Minute
Factors Contributing
to Injury
None
1
2
3
4
5
6
7
8
Asleep
Unconscious
Possibly impaired by alcohol
Possibly impaired by other drug
Possibly mentally disabled
Physically disabled
Physically restrained
Unattended person
Casualty Number
Civilian
EMS, not fire department
Police
Other
Casualty
Number
Female
Ethnicity
1
2
3
4
5
6
7
8
0
U
Change
Suffix
White
Black, African American
Am. Indian, Alaska Native
Asian
Native Hawaiian, Other
Pacific Islander
Exposure
Last Name
1
2
3
4
5
OR
Incident Number
Injured Person
2
3
4
5
6
7
8
9
0
U
NFIRS4
Civilian Fire
Casualty
YYYY
M2
1
2
3
U
Skip to
Section N
M3
M4
Below grade
M5
Below grade
Skip to
Block M5
N
01
11
12
21
33
96
98
Disposition
Transported to emergency care facility
1
2
3
4
5
6
7
8
9
Head
Neck and shoulder
Thorax
Abdomen
Spine
Upper extremities
Lower extremities
Internal
Multiple body parts
Remarks
Local option
NFIRS4
5-26
Revision 01/01/04
NFIRS5
YYYY
Delete
FDID
DD
Incident Date
State
Station
Incident Number
Injured Person
1
2
Identification Number
Male
Female
Exposure
Change
Career
Volunteer
1
2
Fire Service
Casualty
Casualty Number
Casualty Number
First Name
Last Name
MI
Suffix
Midnight is 0000.
Date of Injury
Date of Birth
Time of Injury
OR
In years
G1
1
2
3
4
5
6
7
8
0
H1
Month
Usual Assignment
Suppression
EMS
Prevention
Training
Maintenance
Communications
Administration
Fire investigation
Other
Day
Month
1
2
4
Rested
Fatigued
Ill or injured
Year
Hour
0
U
G4
Other
Undetermined
I1
Minute
Taken To
1
4
5
6
7
0
Severity
1
2
3
4
5
6
7
Not transported
Hospital
Doctors office
Morgue/funeral home
Residence
Station or quarters
Other
Activity at Time of Injury
G5
I3
Object Involved
in Injury
None
Cause of injury
H2
Day
G2
G3
Year
Responses
None
I2
None
Object involved in injury
Contributing factor
J1
1
2
3
4
5
6
7
8
9
0
U
En route to FD location
At FD location
En route to incident scene
En route to medical facility
At scene in structure
At scene outside
At medical facility
Returning from incident
Returning from med facility
Other
Undetermined
J2
Below grade
J3
65
64
63
61
54
53
49
45
36
35
34
33
32
31
28
27
26
25
24
23
22
5-27
J4
Vehicle Type
1
2
3
4
Suppression vehicle
EMS vehicle
Other FD vehicle
Non-FD vehicle
Complete ONLY if
Specific Location code
is >60
Remarks
K1
K2
Yes
Please complete the remainder of this form ONLY if you answer YES.
No
K3
11
12
13
14
15
16
17
10
21
22
23
24
25
26
27
28
20
NFIRS5
Equipment
Sequence
Number
Fire Service
Casualty
11
Burned
12
Melted
21
22
Punctured
23
Scratched
24
Knocked off
25
Cut or ripped
31
32
Insufficient insulation
33
41
42
43
44
45
46
47
48
49
51
52
Special Equipment
53
61
62
63
64
65
66
67
68
69
71
72
73
74
75
76
77
78
79
70
00
94
95
96
97
00
UU
Undetermined
Helmet
Full face protector
Partial face protector
Goggles/eye protection
Hood
Ear protector
Neck protector
Other
Protective coat
Protective trousers
Uniform shirt
Uniform T-shirt
Uniform trousers
Uniform coat or jacket
Coveralls
Apron or gown
Other
Boots or Shoes
31
32
33
34
35
36
37
38
30
Respiratory Protection
41
42
43
44
45
46
40
Hand Protection
51
52
53
54
55
50
5-28
K4
Model
Serial Number
NFIRS5
Revision 05/01/03