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Flue Fire Response 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


Street Number: *
Street/Road Name: *
Street Type:
Community: *
Owner/Occupant: *
Please enter the name of the owner or occupant.
Address:
Enter the address if different than the response location.
Date of the Fire: *
(MM/DD/YYYY)
Time of the Fire: *
Enter hour and minutes.
For example, enter 23:24

Flue Type - Masonry


Was the fire in a masonry chimney or fireplace? If so, what kind of masonry flue was it?
Type of Flue:
Block Clay Lined
Block Stainless Steel Lined
Block Steel Lined (Well Casing etc.)
Block Unlined
Brick Unlined
Brick Clay Lined
Brick Stainless Lined
Brick Bracket Type
Brick Steel Lined (Well Casing etc)
Other:
If other, explain.
Flue Type - Factory Built


Was the fire in a factory built chimney? If so, what kind of factory built chimney was it?
Type of Flue:
Galvanized Steel Round
Galvanized Steel Square
Stainless Steel ULC All Fuel
Stainless Steel ULC Oil and Gas
Steel Well Casing
Other:
If other, explain.
Name Brand of Chimney:
General Information


Appliances: *
Was there more than one appliance connected to the flue?
Yes
No
Chimney Location:
Inside Dwelling
Outside Dwelling
Cleanout Door:
Did the chimney have a cleanout door?
Yes
No
Clearance:
Was there a 2" clearance from combustable floor joists, rafters, etc.?
Yes
No
Unused Openings:
Were unused openings properly sealed?
Yes
No
Masonry Chimneys


Foundation:
Was the foundation made of combustible or non-combustible material?
Non-combustible
Combustible
Cracks:
Were there cracks in the exterior shell or liners?
Yes
No
Creosite:
Were there creosite stains on the exterior shell?
Yes
No
Metal Stops:
Were there metal stops between floors?
Yes
No
Soft Mortar:
Was the mortar soft in the joints?
Yes
No
Factory-Built Chimney


ULC Approved:
Was the factory-built chimney approved for solid fuel?
Yes
No
Non-combustible base:
Was the base support non-combustible?
Yes
No
Factory Components:
Were factory components used between floor and attic?
Yes
No
Exposed Chimney:
Was the chimney exposed on the second floor?
Yes
No
Rust Signs:
Were there rust signs on the outside of the metal shell?
Yes
No
Rain Cap:
Was the rain cap in place?
Yes
No
Height:
Was the approximate height above the roof line more than 6 feet?
Yes
No
Roof Braces:
Were roof braces used?
Yes
No
Remarks:
If there were any events or situations that should be noted, please enter your remarks here.
Chief: *
Or the name of the person submitting the form.

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