NORTH CAROLINA INCIDENT REPORT



| NORTH CAROLINA INCIDENT REPORT |Date |

|Address | |Phone | |

|Owner | |

|Address | |Phone | |

|Apparatus | |Personnel | |Miles(1) Way |

| 100 Fire Other | 1 Received | N None | 20 Function Area/Other | 10 Heat Powered Eq. |

|111 Structure |2 Automatic Received |1 LNG, Small Leak |21 Bedroom < 5 Pers. |11 Equipment Spark |

|113 Cooking |3 Aid Given |2 LPG, < than 21 lb. |24 Cooking/Kitchen |13 Arcing |

|114 Chimney |4 Automatic Aid Given |3 Gasoline |25 Bathroom |43 Hot Ember/Ash |

|121 Mobile Home |5 Other Aid Given |4 Kerosene |26 Laundry Room |61 Cigarette |

|131 Passenger Vehicle |N None |5 Diesel Fuel |27 Office |64 Match |

|132 Road Freight | |6 Household Solvents |35 Computer Room |65 Lighter |

|133 Rail Vehicle | |7 Motor Oil |38 Processing/Mfg. |66 Candle |

|137 Camper/RV | |8 Paints |41 Storage Room |68 Backfire from Eng. |

|138 Heavy Equipment | |0 Other |42 Closet |73 Lightning |

|141 Woods | | |47 Garage/Carport |81 Direct Flame Cont. |

|142 Brush/Grass | | |57 Chimney |83 Flying Brand/Emb. |

|143 Grass | | |60 Equipment Rm. |Other: ____________ |

|150 Outside Rubbish | | |61 Machinery Rm. | |

|154 Dumpster Fire | | |65 Maint./Paint Rm. | |

|251 Excessive Heat | | |71 Crawl Space | |

|300 EMS Call/Other | | |72 Enclosed Porch | |

|311 Assist EMS Crew | | |73 Ceiling/Floor Asbly. | |

|322 10/50 PI | | |74 Attic | |

|323 10/50 Pedestrian | | |75 Wall Area Int. | |

|352 Extrication | | |76 Wall Area Ext. | |

|354 Trench Rescue | | |77 Roof | |

|355 Confined Space | | |80 Vehicle Area/Other | |

|356 High Angle | | |81 Passenger Area | |

|411 Gas/Diesel Spill | | |82 Cargo/Truck Area | |

|412 LNG/LPG Leak | | |83 Engine Area | |

|424 Carbon Monoxide | | |84 Fuel Tank | |

|463 10/50 Gen.Cleanup | | |91 RR right of way | |

|531 Smoke/Odor | | |92 On/Near Highway | |

|561 Unauthorized Burn | | |94 Open Area Outside | |

|600 Good Intent Call | | |95 Wildland/Woods | |

|611 Dispatched/Cancel | | |00 Other: ___________ | |

|651 Smoke Scare | | | | |

|652 Steam, Vapor, Fog | | |UU Undetermined | |

|700 False Alarm | | | | |

|710 Malicious False | | | | |

|735 Alarm System Malf. | | | | |

|743 Smoke Det. Activ. | | | | |

|800 Severe Weather | | | | |

|814 Lightning Strike | | | | |

|900 Special Incident | | | | |

|911 Citizen Complaint | | | | |

|Other: _____________ | | | | |

| |Actions Taken | | | |

| | 11 Extinguishment | | | |

| |12 Salvage & Overhaul | | | |

| |22 Res./Remove Harm | | | |

| |23 Extricate | | | |

| |30 EMS Other | | | |

| |31 First Aid | | | |

| |43 Haz-Mat Spill Ctrl | | | |

| |45 Remove Hazard | | | |

| |51 Ventilate | | | |

| |52 Forcible Entry | | | |

| |53 Evacuate Area | | | |

| |55 Establish Safe Area | | | |

| |62 Light and Air Unit | | | |

| |65 Secure Property | | | |

| |66 Remove Water | | | |

| |70 Assistance, Other | | | |

| |72 Assist Animal | | | |

| |73 Provide Manpower | | | |

| |74 Provide Apparatus | | | |

| |75 Provide Equipment | | | |

| |76 Provide Water | | | |

| |78 Control Traffic | | | |

| |79 Assess WX Damg. | | | |

| |80 Information/ Other | | | |

| |81 Incident Command | | | |

| |82 Notify Other Agencies | | | |

| |86 Investigate | | | |

| |91 Fill in/ Move up | | | |

| |92 Standby | | | |

| |93 Cancelled Enroute | | | |

| |00 Other: ____________ | | | |

| | |Property Use | | |

| | | 131 Church | | |

| | |161 Restaurant | | |

| | |213 Elementary Sch. | | |

| | |215 Middle/ High Sch. | | |

| | |254 Comm. Daycare | | |

| | |255 Res. Daycare | | |

| | |300 Healthcare, other | | |

| | |311 Nursing Home | | |

| | |340 Clinic/Doctor Off. | | |

| | |419 1-2 Family | | |

| | |429 Multi-Family | | |

| | |449 Hotel/Motel | | |

| | |500 Hardware/ Other | | |

| | |511 Convenience Str. | | |

| | |519 Grocery Store | | |

| | |549 Specialty Shop | | |

| | |571 Service Station | | |

| | |592 Bank | | |

| | |599 Business Office | | |

| | |642 Electrical Distrib. | | |

| | |669 Forest/Woods | | |

| | |700 Manufacturing | | |

| | |800 Storage/Other | | |

| | |808 Outbuilding | | |

| | |931 Open Land/Field | | |

| | |961 Highway | | |

| | |962 Residential Street | | |

| | |965 Veh. Parking Area | | |

| | |981 Construction Site | | |

| | |NNN None | | |

| | |Other: _____________ | | |

| | |UUU Undetermined | | |

| | | | |Item First Ignited |

| | | | | 17 Structural Member |

| | | | |20 Furniture |

| | | | |32 Bedding/Blanket |

| | | | |36 Curtains |

| | | | |72 Light Vegetation |

| | | | |73 Heavy Vegetation |

| | | | |76 Cooking Materials |

| | | | |81 Electrical Wire |

| | | | |96 Rubbish/Trash |

| | | | |Other: ____________ |

| | | | |Equipment Involved |

| | | | | |

| | | | |Equipment:___________ |

| | | | |Brand: ______________ |

| | | | |Model: ______________ |

| | | | |Serial #: _____________ |

| | | | |Year: _______________ |

| | | | |Mobile Property |

| | | | |Vehicle: _________ |

| | | | |Brand: __________ |

| | | | |Model: __________ |

| | | | |VIN: ____________ |

| | | | |________________ |

| | | | |Plate: ___________ |

| | | | |State: ___________ |

| | | | |Year: ___________ |

| | | |Cause of Ignition | |

| | | | | |

| | | |1 Intentional | |

| | | |2 Unintentional | |

| | | |3 Failure equip./heat src. | |

| | | |4 Act of Nature | |

| | | | | |

| | | |5 Under Investigation | |

| | | |6 Undetermined | |

| |Injuries/Deaths | | | |

| |Injuries: FF_____ Civ._____ | | | |

| |Deaths: FF_____ Civ._____ | | | |

|Structure Type |Structure Size |Fire Spread |Detector Power Supply |Detector Operation |

| 1 Enclosed Bldg. | | 1 Confined to Object | 1 Battery | 1 Fire to small to act. |

|2 Portable/Mobile Struc. |Length: _____________ |2 Confined to Room |2 Hardwire |2 Operated |

|3 Open Structure |Width: ______________ |3 Confined to Floor |3 Plug in |3 Failed to Operate |

|Other Type |Square Feet: ________ |4 Confined to Building |4 Hardwire w/ Battery |U Undetermined |

| |# Stories Above: ______ |5 Beyond Building |0 Other: ____________ | |

| |# Stories Below: ______ | | | |

| |Story of Origin: _______ | | | |

|Building Status | | | |Detector Failure |

| 1 Under Construction | | |Detector Effectiveness | 1 Power Failure |

|2 Occupied & Opert. | | | |2 Improper Installation |

|3 Idle | | | |3 Defective |

|4 Under major renovat. | | | |4 Lack Maintenance |

|5 Vacant & Secured | | | |5 Battery Missing |

|6 Vacant & Unsecured | | | |6 Battery Dead |

|0 Other | | | |Other: _____________ |

| | |Detector Type | 1 Alerted Occupants | |

| | | |2 Occupants Not Resp. | |

| | | |3 No Occupants | |

| | | |4 Failed to Alert | |

| | | |U Undetermined | |

| |# Stories Damaged | 1 Smoke | | |

| | |2 Heat | | |

| | |3 Combination | | |

| | |0 Other: ____________ | | |

| | | | | |

| |To 25% ___ To 50 % ___ | | | |

| |To 75% ___ To 100% ___ | | | |

|Remarks: |

|MMR |      |Position |      |Assignment|      |

|Driver/Operator | |Action Taken | |

|Personnel | |Action Taken | |

|Personnel | |Action Taken | |

|Personnel | |Action Taken | |

|Personnel | |Action Taken | |

|Personnel | |Action Taken | |

|Apparatus ID |TANKER 22 |# Personnel | |Use |Suppression EMS Other |

|Driver/Operator | |Action Taken | |

|Personnel | |Action Taken | |

|Personnel | |Action Taken | |

|Apparatus ID |SQUAD 24 |# Personnel | |Use |Suppression EMS Other |

|Driver/Operator | |Action Taken | |

|Personnel | |Action Taken | |

|Apparatus ID |SUPPORT 25 |# Personnel | |Use |Suppression EMS Other |

|Driver/Operator | |Action Taken | |

|Personnel | |Action Taken | |

|Personnel | |Action Taken | |

|Personnel | |Action Taken | |

|Personnel | |Action Taken | |

|Apparatus ID |POV |# Personnel | |Use |Suppression EMS Other |

|Personnel | |Presonnel | |

|Personnel | |Personnel | |

|Personnel | |Personnel | |

|Personnel | |Personnel | |

|Personnel | |Personnel | |

|Personnel | |Personnel | |

|Personnel | |Personnel | |

|Personnel | |Personnel | |

|Personnel | |Personnel | |

|Personnel | |Personnel | |

|Personnel | |Personnel | |

|Personnel | |Personnel | |

|Other Personnel Attending |

|Chief Officer | |Chief Officer | |

|Additional Remarks: |

|Mutual Aid Fire Department(s) |

|Stantonsburg Moyton | |Macclesfield | |

|East Nash | |Walstonburg | |

|Bakertown | |Fountain | |

|Black Creek | |Toisnot | |

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