Basic Fire Incident Report - .NET Framework

1 fire REG 1 Appendix BForm A - fire Incident Report (Insurance)[Section 6] fire SAFETY REGULATIONS5 APPROVEDS eptember 18, 2015 - 2:15 BForm A - fire Incident Report (Insurance) [Section 6]Emergency Management and fire SafetyBasic fire Incident ReportPage 1 of 3 fire Department: Incident Time: Incident Date: use 24-hour clock day/ month/ yearIncident Address: / / street address/lot, block and plan #/land location description RM/Town/City/Village/Hamlet postal codeIncident Type: Structure fire Vehicle fire Vegetation fire Garbage fire Other:provide detail of fire Incident if not classified aboveNote:Complete and attach to this Report a fire Detector and Extinguishing Equipment Report and/or a Casualty Report as applicableMutual Aid Mutual Aid Received Mutual Aid GivenResources Number of Apparatus Number of Personnel list total number of apparatus responded list total number of personnel respondedValues Estimated Dollar Value of Property: $ Estimated Dollar Value of Damages: $ Insurance File # Insurance Company: Persons InvolvedInsurance Contact:Phone: Police Contact:Phone: Owner s Name:Phone: Owner s Address:Occupant's NamePhone: fire REG 1 fire SAFETY REGULATIONS6 APPROVEDS eptember 18, 2015 - 2.

2 15 Use Educational Mercantile / Business Storage Health Care / Detention Industry / Utility Outside or special property Residential Manufacturing Other provide property use detail of the structure if not classified aboveNumber of buildings involved Acres burned Building height Floor size Total # of stories Indicate ft or m 22 Building Status Under Construction Under major renovation Being demolished Occupied Vacant and secured Undetermined Idle / Not routinely used Vacant and unsecured Otherprovide details of building status if not classified aboveContinued on Page 2 EMFS 03/15 A-1 fire REG 1 fire SAFETY REGULATIONS7 APPROVEDS eptember 18, 2015 - 2:15 Management and fire SafetyBasic fire Incident ReportPage 2 of 3 fire Spread Confined to room of origin Confined to building of origin Confined to floor of origin Beyond building of originMobile Property InvolvedMobile Property Type None Passenger or road transport Aircraft Not involved with ignition, but burned Freight road vehicle Industrial, agriculture, construction Involved with ignition.

3 But did not burn Transport vehicle Miscellaneous Involved with ignition and burned Water vessel UnknownMobile Property DetailsMakeModelLicence number Province VIN Ignition FactorsArea of Origin provide detailed description of the primary use of the area where the fire started - also check below as applicable Means of egress Storage areas Transportation vehicle areas>hallways, entrance areas, fire exits>store rooms, closets, garages>passenger area, trunk, engine Assembly areas Service areas Outside areas>theaters, community halls, living rooms>conduit, pipes, elevator shaft>streets, parking lots, railway tracks Function area Service or equipment areas Other areas>bedroom, kitchen, office, dining room>mechanical rooms, cells>areas not otherwise listed Technical processing area Structural areas Undetermined>laboratories, operating rooms, stages>attics, crawl spaces, exterior of walls>area or origin cannot be determinedHeat Source provide detailed description of the heat source which ignited the first object to burn - also check below as applicable Operating equipment Other open flame, smoker's materials Other heat sources>spark, ember, electrical arc, radiant heat>cigarettes, candles, match, lighter>multiple heat sources Hot smouldering object Chemical, Natural heat sources Undetermined>heat of friction, molten material, welding>sunlight, spontaneous combustion>heat source cannot be determined Explosives, fireworks Heat spread from another fire >blasting agent.

4 Munitions, fireworks>flame contact, radiant heat, embersItem First Ignited provide detailed description of the item first ignited - also check below as applicable Structural component Adornment, recreational items, signs Organic materials>wall coverings, framing, floor coverings>Christmas trees, awnings, tents, toys>agricultural crops, humans, animals Furniture, utensils Storage supplies General materials>upholstery, cabinets, appliances>boxes, packing materials, pallets>books, trash, dust, lint, tires, fertilizer Soft goods, wearing apparel Liquids, piping, filters Undetermined>mattresses, linen, clothing, drapes>flammable gases / liquids, pipes, ducts>item first ignited cannot be determinedCause of Ignition provide detailed description of the cause of ignition - also check below as applicable Intentional Failure of equipment Cause under investigation>misuse of heat source, incendiary fire >equipment not functioning properly>origin and cause not yet determined Unintentional Act of nature Cause undetermined>careless, reckless, accidental acts>weather, floods, animal behaviour>cause undetermined after investigationEMFS 03/15 A-2 fire REG 1 fire SAFETY REGULATIONS8 APPROVEDS eptember 18, 2015 - 2.

5 15 Management and fire SafetyBasic fire Incident ReportPage 3 of 3 Factors Contributing to Ignitionprovide detailed description of the factors that allowed heat source and combustible materials to come into contact/combine Misuse of materials Design, Installation Deficiency fire spread or control>unsafe use or placement of heat source>design, construction, installation faults>exposure, rekindle, controlled burns Mechanical failure, malfunction Operational Deficiency Undetermined>worn components, control failure, leak>collisions, unattended equipment>ignition factors cannot be determined Electrical failure, malfunction Natural condition>short circuit, arcing, equipment failure>wind, flood, animal behaviourHuman Factorsprovide detailed description of the human factors related to the fire - also check below as applicable Asleep Possible mentally disabled None>occupant(s) asleep at time of fire >persons with permanent disabilities>no persons involved Impaired by alcohol or drugs Physically disabled>impaired occupant(s)

6 Asleep or awake>permanent or temporary disabilities Unattended Multiple persons>persons requiring care left unattended>note number of persons aboveEquipment Involvedin Ignition provide detailed description of equipment involved in ignition - also check below as applicable Heating, ventilation, air conditioning Commercial and medical equipment Electronic, other electrical equipment>furnace, fire place, stove, water heater>vending machines, O2 equipment>computers, TVs, stereos, cash register Electrical distribution, lighting, power Garden tools, agricultural equipment Personal and household equipment>distribution panels, outlet, lights>combine, chain saw, milking machine>clothes dryer, curling iron, powered toys Shop tools and industrial equipment Kitchen and Cooking Equipment Other equipment involved in ignition>power saw, welding torch, compressor>Coffee maker, microwave, dishwasher>other equipment not listed, noneBrand or MakeSerial Number or other identificationModelYear of manufactureRemarksPerson Completing This ReportName Rank/Title PhoneWork Home Cell Representing government agency, firm or corporation - provide addressOther Forms filed with this Report : Casualty Report fire Detector and Extinguishing Equipment ReportEMFS 03/15 A-3