Number range CHAPTER

**APPENDIX 06-4**

![](media/image1.png){width="0.6173611111111111in"
height="0.4895833333333333in"}**S A F E N E T**

**Wildland Fire Safety and Health Network**

**[REPORTED BY]{.mark}**

Name (optional) Phone

Agency/Organization Date Reported

**[EVENT]{.mark}**

Date and Time Jurisdiction/Local Unit

Incident Name & Number State

+-----------------------+-----------------------+-----------------------+
| **Incident Type**     | **Incident Activity** | **Stage of Incident** |
|                       |                       |                       |
|  Wildland            |  Line                |  Initial Attack      |
|                       |                       |                       |
|  Prescribed          |  Support             |  Extended Attack     |
|                       |                       |                       |
|  Wildland Fire Use   |  Transport to/from   |  Transition          |
|                       |                       |                       |
|  All Risk            |                      |  Mop Up              |
|                       | R                     |                       |
|  Training            | eadiness/Preparedness |  Demobe              |
|                       |                       |                       |
|  Fuel Treatment      |                       |  Non-Incident        |
|                       |                       |                       |
|  Work Capacity Test  |                       |  Other               |
+-----------------------+-----------------------+-----------------------+

**Position Title**

**Task**

**Management Level**

**Resources Involved**

**[CONTRIBUTING FACTORS]{.mark}**

 Fire Behavior  Environmental  Communications

 Human Factors  Equipment  Other (Explain Below)

Other:

**[NARRATIVE]{.mark}**

> Describe in detail what happened including the concern or potential
> issue, the environment (weather, terrain, fire behavior, etc), and the
> resulting safety/health issue. If more room is required, write on a
> separate piece of paper and include it with this form

![](media/image1.png){width="0.6173611111111111in"
height="0.4895833333333333in"}

![](media/image2.wmf){width="2.3027777777777776in"
height="0.5048611111111111in"}

> **SAFENET**
>
> **PO BOX 16645**
>
> **BOISE ID 83715-9750**

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![](media/image1.png){width="0.49027777777777776in"
height="0.38958333333333334in"}

**S A F E N E T**

**Wildland Fire Safety and Health Network**

The purpose of SAFENET is:

> 1\. To provide reporting and documentation of unsafe situations or
> close calls.
>
> 2\. To provide a means of sharing safety information throughout the
> fire community.
>
> 3\. To provide long-term data that will result in identifying trends.

**Submitting a SAFENET is not a substitute for on the spot
corrections!**

> **When filing a SAFENET:**
>
> You have the option of submitting SAFENET at any level of the
> organization, but are encouraged to submit it to your supervisor for
> immediate corrective action.
>
> If you submit SAFENET directly to the national center, you are
> encouraged to provide a copy to your supervisor.
>
> You have the right to report unsafe conditions anonymously, in
> accordance with 29 CFR 1960.

**File a SAFENET by Phone**

**1-888-670-3938**

............................................................................................................

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**PMS 405-2 (3/00) NFES 2633**