Please Print - Cole County Fire Protection District

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COLE COUNTY FIRE PROTECTION DISTRICT 5206 MONTICELLO ROAD  JEFFERSON CITY, MO 65109 PHONE: 573.634.9011  FAX: 573.634.9004 On Line Incident Report Incident No. _______________ Company No. ____________________________ Date ____________________________________ Incident __________________ Location __________________________________________________________________________ On Scene _________________ Occupant Name ______________________________________ Phone # _____________________ Under-Control _____________ Owner Name _________________________________________ Phone # _____________________ Clear Scene ________________ Address ___________________________________________________________________________ In Quarters_________________ Incident Type (What the incident actually was – Check only one) ______111 Building Fire ______112 Fire in structure other than bldg ______113 Cooking fire, contained to container ______114 Chimney, flue fire, structure not ______130 Vehicle Fire ______131 Passenger Vehicle fire ______137 Camper, RV fire ______141 Natural Cover Fire ______151 Outside rubbish, trash, waste fire ______424 CO Incidents ______531 Smoke, Odor removal ______611 Cancelled Enroute ______621 Wrong location ______631 Control Burn Aid Given or Received: ______1 – Mutual Aid Received ______3 – Mutual Aid Given ______N – None Action Taken (Check all that apply) ______11 Extinguish ______22 Rescue ______24 Recover body ______43 HazMat control Fire Casualties # Fire Service Civilian Fire Casualties ______45 Remove Hazard ______51 Ventilate ______53 Evacuate area ______78 Control traffic Fatal ______Not residential ______Buildings not involved ______00 Action taken other (be specific) _______________________ __________ __________ ______# Fire Suppression Apparatus ______# Other (POV’s/Chief Vehicle etc.) Fire Report Only: Property Name of Department ___________________________ ______86 Investigate ______92 Standby ______93 Cancelled Enroute Resources ______131 Church ______419 1 or 2 family dwelling ______429 Multi-family dwelling ______511 Convenience store ______579 Motor vehicle repair ____________________________ Non Fatal _____ _____ Property Use ______651 Smoke scare ______700 False Call ______745 Alarm system sounded, no fire ______746 CO detector activation, no CO ______Other (be specific) ______# Personnel on Apparatus ______# Personnel ______655 Crops, orchard ______659 Livestock production ______669 Forest, timberland, woodland ______808 Outbuilding or shed ______881 Detached garage ______None ______Less than 1 acre burned ______931 Open land, field ______961 Highway or divided highway ______962 Residential St, Rd, or Driveway ______Other (be specific) ______________________________________ ______# of Residential Units ______# of Building involved ______# of acres burned Fire Report Only: On-Site Materials (Report only if significant quantities present, involved or not) ______131 Trees, plants, flowers ______132 Feed grain, seed ______133 Hay, straw ______134 Crop, Not grain ______211 Curtains, drapes ______213 Bedding ______221 Clothes ______241 Furniture ______242 Beds, mattresses ______311 Lumber, sawn wood ______312 Timber ______410 Paper Products ______510 Flammables Liquids ______511 Gasoline, diesel fuel ______514 Motor oil ______522 LP Gas ______613 Tools (power & hand) ______620 Construction supplies ______625 Lighting ______626 Electrical equipment ______631 Carpets ______632 Linoleum, tile ______635 Paint ______711 Appliances Fire Report Only: On-Site Materials Storage Use ______1 Bulk storage or warehousing ______2 Processing or manufacturing Fire Report Only: Area of Origin ______21 Bedroom ______24 Cooking area, kitchen ______25 Bathroom ______26 Laundry area ______41 Storage room, tank, bin ______42 Closet ______43 Storage, supplies or tools ______47 Vehicle storage, garage, carport Fire Report Only: Heat Source ______11 Operating equip. ______13 Arcing ______41 Heat from friction ______43 Hot ember or ash ______3 Package goods for sale ______4 Repair or Services ______65 Maintenance Shop ______74 Attic, vacant ______77 Roof surface ______81 Passenger area, vehicles ______82 Cargo, trunk area, vehicle ______83 Engine, running gear ______84 Fuel tank, lines ______92 On/near highway, road, parking ______54 Fireworks ______61 Cigarette ______64 Match ______73 Lightning ______712 Electronic equipment ______810 Motor vehicles ______814 Tires ______913 Pallets ______Other (be specific) __________________________ ______N None ______94 Yard, field, pasture ______95 Wildland, woods ______98 Vacant structure ______UU – Undetermined ______Other (be specific) _____________________________________ ______81 Heat from direct flame ______82 Radiated heat/other fire ______83 Flying ember, spark ______UU – Undetermined ______Other (be specific) __________________________ Fire Report Only: First Item Ignited: ______11 Exterior roof ______12 Exterior wall ______14 Floor covering ______16 Interior ceiling ______17 Structural member ______21 Upholstered sofa, chair, seat ______25 Appliance housing ______30 Wearing apparel ______31 Mattress, pillow ______32 Bedding, blanket ______36 Curtains, blinds ______62 Flammable liq/gas in/from engine ______64 Flammable liq/gas contained ______65 Flammable liq/gas uncontained ______71 Agricultural Crop ______72 Grass, pasture, yard Fire Report Only: Type of Material Ignited ______12 LP Gas ______23 Gasoline ______25 Diesel Fuel ______27 Oil ______41 Plastic ______51 Rubber Fire Report Only: Cause of Ignition ______1 Intentional ______2 Unintentional Fire Report Only: Factors of Ignition ______10 Miss use of product ______12 Heat to close to combustibles ______13 cutting, welding too close ______14 Flammable spilled ______15 Improper fueling Fire Report Only: Equipment Involved ______121 Fireplace, masonry ______123 Fireplace, insert, stove ______126 Chimney, brick, stone, mason ______127 Chimney, metal ______131 Furnace ______141 Heater ______151 Water heater ______210 Electrical wiring ______217 Outlet, receptacle ______213 Wall switch ______230 Lamp, lighting ______233 Incandescent light fixture Fire Report Only: Equipment Source ______11 Electrical (>750 volts) ______12 Batteries (< 50 volts) ______22 LP Gas ______54 Hay, straw ______55 Grain, natural fiber ______63 Sawn wood ______65 Fiberboard, particle board ______67 Paper ______68 Car-board ______3 Failure of equipment ______4 Act of Nature ______71 Fabric, fiber ______UU – Undetermined ______Other (be specific) ____________________________ ______5 Cause under investigation ______6 Undetermined ______20 Mechanical failure ______26 Backfire ______34 Short – circuit ______51 Collision, turn over ______61 High Wind ______62 Storm ______72 Rekindle ______73 Outside/open fire-debris burning ______75 Agriculture or land management ______UU – Undetermined ______234 Fluorescent light fixture ______262 Power cord, perm ______263 Extension cord ______310 Power tool ______331 Welding torch ______332 Cutting torch ______365 Bearing or brake ______511 Combine ______512 Hay processing equipment ______524 Lawn mower ______500 Garden, ag, equip, other ______631 Coffee maker ______31 Gasoline ______33 Diesel ______41 Wood ______637 Toaster ______644 Microwave Oven ______641 Range w/or w/o oven ______656 Refrigerator ______811 clothes dryer ______834 Vacuum cleaner ______845 Hair dryer ______853 Heating pad ______NNN – None ______UUU – Undetermined ______Other (be specific) ________________________________ ______00 Other (be specific) ______________________________ Fire Report Only: Mobile Property Involved ______11 Passenger car ______12 Bus ______14 Motor home, RV ______17 Mobile Home ______21 General use truck ______73 Trees and Brush ______76 Cooking materials ______81 Electrical wire, insulation ______84 Tire ______94 Dust, lint, sawdust ______UU - Undetermined ______Other (be specific) _____________________________ ______23 Trailer, semi ______24 Tank truck nonflammable group ______25 Tank truck-flammable cargo ______26 Tank truck compressed gas cargo ______61 Construction Vehicle ______65 Agricultural vehicle ______71 Home garden vehicle ______00 – Other (be specific) ________________________________________________________ Fire Report Only: Mobile Property Involved Information Equipment/Vehicle Make: _____________________________________________________________________________________________ Model: _______________________________________________________________________________Year: __________________________ License Plate #________________________________________________________________________State: __________________________ VIN: ________________________________________________________________________________________________________________ Insurance Information: ________________________________________________________________________________________________ Structure Fire Report: Structure Type ______1 Enclosed building ______2 Portable/Mobile structure ______3 Open structure Structure Fire Report: Building Status ______1 Under construction ______2 Occupied and Operating ______3 Idle, not routinely used Structure Fire Report: Building Height ______# of Stories above ground Structure Fire Report: Main Floor Size __________Total square feet ______4 Air supported structure ______5 Tent ______6 Open platform (e.g. piers) ______4 Under major renovation ______5 Vacant & secured ______6 Vacant and unsecured ______7 Underground structure ______8 Connective structure (e.g.fences) ______0 other type of structure ______7 Being demolished ______U - Undetermined ______0 Other (be specific) _______ ______# of Stories below ground __________ Length X _________ Width Structure Fire Report: Fire Origin ______Story of fire origin ______Below grade Structure Fire Report: Fire Spread ______1 Confined to object of origin ______2 confined to room of origin ______3 Confined to floor of origin ______4 Confined to building of origin ______5 Beyond building of origin Structure Fire Report: Presence of Detectors ______1 Present ______N Not present Structure Fire Report: Detector Type ______1 Smoke ______2 Heat ______U Unable to determine ______3 combination smoke – heat ______4 Sprinkler, water flow detection Structure Fire Report: Detector Power Supply ______1 Battery only ______2 Hardwire only ______3 Plug in ______4 Hardwire w/battery ______5 Plug in w/battery ______6 Mechanical Structure Fire Report: Detector Operation ______1 Fire too small to activate ______2 Operated ______5 More than one type present ______U – Undetermined ______7 Multiple detectors & power supplies ______U – Undetermined ______3 Failed to operate ______U – Undetermined Structure Fire Report: Detector Effectiveness ______1 Alerted occupants, occupants responded ______2 Occupants failed to respond ______3 There were no occupants ______4 Failed to alert occupants ______U – Undetermined Structure Fire Report: Detector Failure Reason ______1 Power failure, shutoff or disconnect ______2 Improper installation or placement ______3 Defective ______4 Lack of maintenance, includes cleaning ______5 Battery missing or disconnected ______6 Battery discharged or dead ______U – Undetermined Check all Personnel on scene Radio Badge Name On Scene Radio Badge Name 110 1 Braun, Donnie 135 152 Rademann, Jim 111 2 Smith, Gary W. 136 79 Hammann, Jason 112 3 Hammann, Wayne 138 80 Hammann, Josh 113 51 Kempker, Tom 139 30 Hart, Mike 114 5 Rackers, Mike 140 122 Long, Matthew 116 7 Cearlock, Steve 142 141 Middlecamp, Allee 117 8 Hammann, Galen 143 167 Lewis, Brian 118 9 Hammann, Robbie 144 35 Braun, Alan 119 138 Gish, Aron 145 109 Angerer, Chuck 120 161 Braun, Justin 146 115 Berendzen, Eric 121 199 Farr, Bill 147 142 Wieberg, Kevin 122 13 Barnes, Steve 148 166 Rush, Garret 123 6 Braun, Gary 149 165 Nacy, Chris 124 4 Braun, Steve 150 143 Kempker, Jerry 125 133 Bopp, Blake 151 145 Morris, Rachel 126 17 Rizner, Larry 152 120 Moore, John 127 18 Gordon, Richard 153 150 Prenger, Matt 128 19 Call, James G. 154 126 Moore, James 129 20 Braun, Bill 156 49 Hammann, Chris 130 135 Jones, Mike 157 169 Berendzen, Bob 131 22 Barnard, Larry 158 52 Berendzen, David 132 21 Berendzen, Gary 159 53 Engelbrecht, Larry 133 148 Graham, Travis 160 54 Kempker, Scott 134 25 Wilbers, Robert 161 67 Schulte, Bernard On Scene Radio Badge Name On Scene 162 144 Petty, Kyle 163 164 Curry, Nacy 164 147 James Feltrop 165 83 York, Shawn 166 158 Lepper, Bradley 167 151 Isenberg, Clayton 168 153 Bashore, Adam 169 86 Luebbering, Dave 170 154 Luebbering, Jill 171 88 Cortvrient, Alan 172 157 Wirtel, William 173 160 Middlecamp, Brady 175 162 Lamberson, Brad 177 94 Luebbering, Doug 178 37 Benz, Larry 179 95 Luebbering, Josh 180 96 Luebbering, Myron 181 97 Luebbering, Nathan 182 163 Ferkel, Chris 183 128 Morris, Bryan 184 129 Williams, Daron 185 130 Bittle, Jason 186 102 Otto, Norman 515 136 Carsten, Pam Check all Apparatus on scene: 1101 1110 1120 1201 1210 1220 1221 1251 1301 1310 1311 1320 1401 1410 1420 1431 1501 1510 1511 1520 1531 1601 1610 1620 1621 1622 1701 1702 1710 1720 Generator 1801 1831 Trailer Narrative: Description of incident, fire department action and tactics, your company action and sketch of incident. (Use additional sheets if necessary) Signatures PREPARED BY SIGN AND DATE INCIDENT COMMANDER SIGN AND DATE APPROVED BY (ASSISTANT CHIEF) SIGN AND DATE