FIRE INCIDENT REPORT FORMINDIVIDUAL FILING REPORT

Full Name: [FULL NAME] Title/Role: [TITLE/ROLE]
Signature:                                                           Date: [MM/DD/YYYY]

INCIDENT DETAILSDate of Incident: [DATE OF INCIDENT]      Time: [TIME] ☐ AM ☐ PM

Location: [LOCATION]

Status of Fire Alarms: ☐ Working ☐ Not Working ☐ Not Present

Cause of Incident: [CAUSE OF INCIDENT]

Describe the Incident: [DESCRIBE THE INCIDENT]

PARTIES INVOLVED

1. Full Name: [FULL NAME] Phone: [PHONE] E-Mail: [EMAIL] Address: [ADDRESS]
2. Full Name: [FULL NAME] Phone: [PHONE] E-Mail: [EMAIL] Address: [ADDRESS]
3. Full Name: [FULL NAME] Phone: [PHONE] E-Mail: [EMAIL] Address: [ADDRESS]
4. Full Name: [FULL NAME] Phone: [PHONE] E-Mail: [EMAIL] Address: [ADDRESS]

INJURIES AND FATALITIESWas anyone injured? ☐ Yes ☐ No    How many people were injured? [#]

If yes, describe the injuries: [INJURY DESCRIPTION]

Were there any fatalities? ☐ Yes ☐ No   How many? [#]

If yes, list their names: [FATALITIES]

PROPERTY DAMAGE

Was there any property or equipment damage? ☐ Yes ☐ No

If yes, describe the injuries: [PROPERTY DAMAGE DESCRIPTION]

FIRE DEPT./MEDICAL SERVICESFire Dept. Notified?☐ Yes ☐ No

If yes, at what time? [TIME] ☐ AM ☐ PM

Time of Arrival: [TIME] ☐ AM ☐ PM

Was medical treatment provided? ☐ Yes ☐ No ☐ Refused

If yes, where was medical treatment provided? ☐ On site ☐ Hospital ☐ Other: [OTHER]