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Casualty Report - Office of the Fire Marshal

Fields marked with a red star (*) are mandatory.

Fire Department


Fire Department: *
Please select your fire department.
Fire Department Number: *
Please enter your unique Fire Department Number.
Report Number:
Form
Fire Information


Date of the Fire: *
(MM/DD/YYYY)
Time of Fire:
Enter hour and minutes.
For example, enter 23:37

Casualty Identification


Casualty Name: *
Street Number: *
Street Name: *
Street Type:
Community: *
Casualty Number:
Casualty Information


Sex: *
Male
Female
Age:
Physical Condition: Suspected:

If you checked Impaired - Drugs or Impaired - Alcohol, please provide details in the Remarks area.

Infant - Too Young to Act
Children Left Unattended
Under Restraint or Detention
Bedridden or Other
      Physical/Mental Handicap
Impaired - Alcohol
Impaired - Drugs
Asleep
Normal - Involved in Domestic Household
Activities
Normal - Involved in Leisure/Recreational
Activities
Normal - Involved in Business/Occupational 
Activities
Unknown or Unclassified

Action of Casualty: Suspected:
Panic or Loss of Judgment
Attempting Escape
Responding to or Returning from Alarm
Involved in Rescue Activities
Involved in Firefighting Activities
Removing Endangered Property or
      Equipment
No Action
Unknown or Unclassified
Cause of Injury or Death:
Smoke or Fire
Explosion
Falling Debris
Building Collapse
Equipment Failure - Occurence Related
Accident - Occurence Related
Equipment Failure - Training Activity
Accident - Training Activity
Unknown or Unclassified

Injury (observed or suspected):
Head‚ Neck or Spine Injury
Wounds - Incised‚ Lacerated‚
     Punctured‚ etc.
Heart Attack or Stroke
Bone Injury or Fracture
Burns or Scalds
Asphyxia‚ Respiratory Condition
Injury to Muscle‚ Ligaments or Joints
Eye Injury
Traumatic Shock
Heat Illness‚ Cold Exposure or Fatigue
Minor Cuts or Bruises
Unknown or Unclassified
Severity:
Minor - Not Hospitalized No
      absence from Work
Serious - Hospitalized
     and/or Absence from Work
Fatal
Clothing:
Did the type of clothing worn by the casualty contribute to the severity?
If yes, please explain in the Remarks section.

No
Yes
Firefighter Casualty


If the casualty was a firefighter, provide the following details.
Employment Status:
Full Time
Part Time (Volunteer)
Firefighting Experience:
Years
Height:
Centimetres
Weight:
Kilograms
Clothing/Equipment:
What clothing or equipment was the firefighter wearing at the time of injury?
Helmet
Helmet Liner
Face Shield
Other Eye Protection
Coat (Turnout)
Gloves (Mitts)
Boots
Hose Key Belt
Breathing Appartus (Self-contained)
Remarks:
Chief: *
Or name of the person submitting the report

Do you want a copy of the form?


Please send me a simple text-only version of the information I submitted.
Please send me an Acrobat version of the form, with the information I've entered above filled in, that I can print and save.
Please send me both the text-only version and the PDF.
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