1 

2 

U 

C Incident Type 

Incident Type 

PRE-INCIDENT VALUE: Optional 

G Estimated Dollar Losses and Values 2 

LOSSES: None 

Property $ , , 

Contents $ , , 

Property $ , , 

Contents $ , , 

Check this box and skip this block if an 

Apparatus or Personnel Module is used. 

Apparatus Personnel 

Check box if resource counts include aid 

received resources. 

EMS 

Other 

Suppression 

G Resources 1 

Completed Modules 

Fire–2 

Structure Fire–3 

Civilian Fire Cas.–4 

Fire Service Cas.–5 

EMS–6 

HazMat–7 

Wildland Fire–8 

Apparatus–9 

Personnel–10 

Arson–11 

E2 Shifts and Alarms 

Shift or 

Platoon 

Alarms District 

Local Option 

E3 Special Studies 

Special 

Study ID# 

Special 

Study Value 

Local Option 

NFIRS–1 Revision 01/01/07 

J Property Use 

Outside

Property Use 

Mixed Use 

Property 

I 

10 

20 

33 

40 

51 

53 

58 

59 

60 

63 

65 

00 

Not mixed 

Assembly use 

Education use 

Medical use 

Residential use 

Row of stores 

Enclosed mall 

Business & residential 

Office use 

Industrial use 

Military use 

Farm use 

Other mixed use 

131 

161 

162 

213 

215 

241 

311 

331 

Structures

Church, place of worship 

Restaurant or cafeteria 

Bar/Tavern or nightclub 

Elementary school, kindergarten 

High school, junior high 

College, adult education 

Nursing home 

Hospital 

341 

342 

361 

419 

429 

439 

449 

459 

464 

519 

Clinic, clinic-type infirmary 

Doctor/Dentist office 

Prison or jail, not juvenile 

1- or 2-family dwelling 

Multifamily dwelling 

Rooming/Boarding house 

Commercial hotel or motel 

Residential, board and care 

Dormitory/Barracks 

Food and beverage sales 

539 

571 

579 

599 

615 

629 

700 

819 

882 

891 

124 

655 

669 

807 

919 

931 

Playground or park 

Crops or orchard 

Forest (timberland) 

Outdoor storage area 

Dump or sanitary landfill 

Open land or field 

936 

938 

946 

951 

960 

961 

962 

Vacant lot 

Graded/Cared for plot of land 

Lake, river, stream 

Railroad right-of-way 

Other street 

Highway/Divided highway 

Residential street/driveway 

981 

984 

Construction site 

Industrial plant yard 

Household goods, sales, repairs 

Gas or service station 

Motor vehicle/boat sales/repairs 

Business office 

Electric-generating plant 

Laboratory/Science laboratory 

Manufacturing plant 

Livestock/Poultry storage (barn) 

Non-residential parking garage 

Warehouse 

Look up and enter a 

Property Use code and 

description only if you 

have NOT checked a 

Property Use box. 

None 

Deaths Injuries 

Casualties 

Fire 

Service 

Civilian 

Detector H2 

Required for confined fires. 

Detector alerted occupants 

Detector did not alert them 

Unknown 

H3 Hazardous Materials Release None 

Natural gas: slow leak, no evacuation or HazMat actions 

Propane gas: <21-lb tank (as in home BBQ grill) 

Gasoline: vehicle fuel tank or portable container 

Kerosene: fuel burning equipment or portable storage 

Diesel fuel/fuel oil: vehicle fuel tank or portable storage 

Household solvents: home/office spill, cleanup only 

Motor oil: from engine or portable container 

Paint: from paint cans totaling <55 gallons 

Other: special HazMat actions required or spill > 55 gal 

(Please complete the HazMat form.) 

1 

2 

3 

4 

5 

6 

7 

8 

0 

Census Tract -

Delete A 

Change 

NFIRS–1 Basic OMB 1660-0069 

Expires 04/30/2019 

*Paperwork Burden 

Notice on Back No Activity 

Cross Street, Directions or National Grid, as applicable 

Number/Milepost Prefix Street or Highway Street Type Suffix 

Apt./Suite/Room City State ZIP Code 

-

B Location Type 

Street address 

Intersection 

In front of 

Rear of 

Adjacent to 

Directions 

Check this box to indicate that the address for this incident is provided on the Wildland Fire 

Module in Section B, “Alternative Location Specification." Use only for wildland fires. 

U.S. National Grid 

Primary Action Taken (1) 

Additional Action Taken (2) 

Additional Action Taken (3) 

Actions Taken F 

Their FDID 

Their Incident Number 

Their 

State 

Mutual aid received 

Auto. aid received 

Mutual aid given 

Auto. aid given 

Other aid given 

None 

1 

2 

3 

4 

5 

D Aid Given or Received 

E1 Dates and Times Midnight is 0000 

Month Day Year Hour Min 

ALARM always required 

ARRIVAL required, unless canceled or did not arrive 

CONTROLLED optional, except for wildland fires 

LAST UNIT CLEARED, required except for wildland fires 

Check boxes if 

dates are the 

same as Alarm 

Date. 

Alarm 

Arrival 

Controlled 

Last Unit 

Cleared 

FDID Incident Date Station Incident Number Exposure 

MM DD YYYY 

State 

H1 

Code 

Property Use Description 

Required for all fires if known. 

Optional for non-fires. 

None 
*PAPERWORK BURDEN DISCLOSURE NOTICE 

NFIRS-1 

Paperwork burden for this form (NFIRS Version 5.0 Modules 1-12 (Electronic)) is estimated to average 27 minutes per response. The burden estimate includes 

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comments regarding the accuracy of the burden estimate and any suggestions for reducing the burden to: Information Collection Management, Department of 

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NOTE: Do not send your completed form to this address. 
More remarks? Check this box and attach Supplemental Forms (NFIRS–1S) as necessary. 

Remarks: 

Local Option 

L 

ITEMS WITH A MUST ALWAYS BE COMPLETED! 

Business Name (if applicable) 

Check this box if same 

address as incident 

location (Section B). 

Then skip the three 

duplicate address 

lines. 

Owner K2 

Local Option Area Code Phone Number 

Mr., Ms., Mrs. First Name MI Last Name Suffix

State ZIP Code

Apt./Suite/Room City

Number Prefix Street or Highway Street Type Suffix

Same as person involved? 

Then check this box and skip 

the rest of this block. 

Post Office Box 

More people involved? Check this box and attach Supplemental Forms (NFIRS–1S) as necessary. 

Business Name (if applicable) 

Check this box if same 

address as incident 

location (Section B). 

Then skip the three 

duplicate address 

lines. 

K Person/Entity Involved 1 

Local Option Area Code Phone Number 

Mr., Ms., Mrs. First Name MI Last Name Suffix

State ZIP Code

Post Office Box Apt./Suite/Room City

Number Prefix Street or Highway Street Type Suffix

M Authorization 

Officer in charge ID Signature Position or rank Assignment Month Day Year

Member making report ID Signature Position or rank Assignment Month Day Year 

Check box if 

same as 

Officer in 

charge. 

Check the box that applies and then complete the Fire Module 

based on Incident Type, as follows: 

Fire Module Required? 

Buildings 111 

Special structure 112 

Confined 113–118 

Mobile property 120–123 

Vehicle 130–138 

Vegetation 140–143 

Outside rubbish fire 150–155 

Special outside fire 160 

Special outside fire 161–164 

Crop fire 170–173 

Complete Fire & Structure Modules 

Complete Fire Module & 

Section I, Structure Module 

Basic Module Only 

Complete Fire & Structure Modules 

Complete Fire Module 

Complete Fire or Wildland Module 

Basic Module Only 

Complete Fire or Wildland Module 

Complete Fire Module 

Complete Fire or Wildland Module 
*PAPERWORK BURDEN DISCLOSURE NOTICE 

NFIRS-1 

Paperwork burden for this form (NFIRS Version 5.0 Modules 1-12 (Electronic)) is estimated to average 27 minutes per response. The burden estimate includes 

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comments regarding the accuracy of the burden estimate and any suggestions for reducing the burden to: Information Collection Management, Department of 

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MM DD YYYY NFIRS–1S Supplemental 

Dele OMB 1660-0069 A te Expires 04/30/2019 

*Paperwork Burden FDID State Incident Date Station Incident Number Exposure Change Notice on Back 

Check this box if 

same address as 

Person/Entity Involved K1 Business Name (if applicable) Area Code Phone Number Local Option 

Mr., Ms., Mrs. First Name MI Last Name Suffix incident location. 

Then skip these three 

duplicate address 

lines. Number Prefix Street or Highway Street Type Suffix 

Post Office Box Apt./Suite/Room City 

State ZIP Code 

Person/Entity Involved K1 Business Name (if applicable) Area Code Phone Number Local Option 

Mr., Ms., Mrs. First Name MI Last Name Suffix incident location.
 

Then skip these
 

these duplicate
 

address lines. Number Prefix Street or Highway Street Type Suffix 

Check this box if 

same address as 

Post Office Box Apt./Suite/Room City 

State ZIP Code 

Person/Entity Involved K1 Business Name (if applicable) Area Code Phone Number Local Option 

Mr., Ms., Mrs. First Name MI Last Name Suffix incident location. 

Then skip these three 

duplicate address 

lines. Number Prefix Street or Highway Street Type Suffix 

Check this box if 

same address as 

Post Office Box Apt./Suite/Room City 

State ZIP Code 

Person/Entity Involved K1 Business Name (if applicable) Area Code Phone Number Local Option 

Mr., Ms., Mrs. First Name MI Last Name Suffix incident location.
 

Then skip these three
 

duplicate address
 

lines. Number Prefix Street or Highway Street Type Suffix 

Check this box if 

same address as 

Post Office Box Apt./Suite/Room City 

State ZIP Code 

Person/Entity Involved K1 Business Name (if applicable) Area Code Phone Number Local Option 

Mr., Ms., Mrs. First Name MI Last Name Suffix incident location. 

Then skip these three 

duplicate address 

lines. Number Prefix Street or Highway Street Type Suffix 

Check this box if 

same address as 

Post Office Box Apt./Suite/Room City 

State ZIP Code NFIRS–1S Revision 01/01/07 
*PAPERWORK BURDEN DISCLOSURE NOTICE 

NFIRS-1S 

Paperwork burden for this form (NFIRS Version 5.0 Modules 1-12 (Electronic)) is estimated to average 27 minutes per response. The burden estimate includes 

the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and submitting the form. You 

are not required to respond to this collection of information unless a valid OMB control number is displayed in the upper right corner of this form. Send 

comments regarding the accuracy of the burden estimate and any suggestions for reducing the burden to: Information Collection Management, Department of 

Homeland Security, Federal Emergency Management Agency, 500 C Street, SW, Washington, DC 20472. Paperwork Reduction Project (1660-0069) 

NOTE: Do not send your completed form to this address. 
 

 L 

NFIRS–1S Supplemental Special Studies E3 Supplemental Local Option 

1 2 3 4 

Special Special Special Special Special Special Special Special 

Study ID# Study Value Study ID# Study Value Study ID# Study Value Study ID# Study Value 

5 6 7 8

Special Special Special Special Special Special Special Special 

Study ID# Study Value Study ID# Study Value Study ID# Study Value Study ID# Study Value 

Remarks: 

Local Option 

NFIRS-1S Revision 01/01/07 
*PAPERWORK BURDEN DISCLOSURE NOTICE 

NFIRS-1S 

Paperwork burden for this form (NFIRS Version 5.0 Modules 1-12 (Electronic)) is estimated to average 27 minutes per response. The burden estimate includes 

the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and submitting the form. You 

are not required to respond to this collection of information unless a valid OMB control number is displayed in the upper right corner of this form. Send 

comments regarding the accuracy of the burden estimate and any suggestions for reducing the burden to: Information Collection Management, Department of 

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NOTE: Do not send your completed form to this address. 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

FDID Incident Date Station Exposure 

MM DD YYYY 

State 

A Delete 

Change 

F3 Equipment Portability 

Portable 

Stationary 

Portable equipment normally can be moved by 

one or two persons, is designed to be used in 

multiple locations, and requires no tools to install. 

1 

2 

F2 Equipment Power Source 

Equipment Power Source 

D 

Area of fire origin 

Heat source 

Item first ignited 

Type of material first ignited 

D1 

D2 

D3 

D4 

Ignition 

Check box if fire spread was 

confined to object of origin. 

Required only if item first. 

ignited code is 00 or <70. 

1 

Fire suppression factor (1) 

Fire suppression factor (2) 

Fire suppression factor (3) 

G Fi None re Suppression Factors 

Enter up to three codes. 

, 

Acres burned (outside fires) 

Not Residential 

Number of buildings involved 

Estimated number of residential living units in 

building of origin whether or not all units 

became involved. 

B2 

B3 

Buildings not involved 

Less than one acre 

None 

Property Details 

B1 

B 

Factor contributing to ignition (1) 

Factor contributing to ignition (2) 

Factors Contributing to Ignition None E2 

Intentional 

Unintentional 

Failure of equipment or heat source 

Act of nature 

Cause under investigation 

Cause undetermined after investigation 

E1 Cause of Ignition 

Check box if this is an exposure report. 

1 

2 

3 

4 

5 

U 

Skip to 

Section G 

Mobile property type 

License Plate Number State 

Mobile property model Year 

Mobile Property Type and Make H2 

VIN 

Structure fire? Please be sure to complete the Structure Fire form (NFIRS–3). 

Mobile property make 

None 

Equipment Involved in Ignition 

Equipment Involved 

Brand 

Year 

F1 

Model 

Serial # 

If equipment was not involved, skip to 

Section G. 

Asleep 

Possibly impaired by 

alcohol or drugs 

Unattended person 

Possibly mentally disabled 

Physically disabled 

Multiple persons involved 

E3 

Human Factors 

Contributing to Ignition 

Check all applicable boxes 

None 

Age was a factor 

Estimated age of 

person involved 

1 Male 2 Female 

1 

2 

3 

4 

5 

6 

7 

Complete if there were any significant amounts of 

commercial, industrial, energy, or agricultural products 

or materials on the property, whether or not they became involved. 

Enter up to three codes. Check one box for each code 

entered. 

On-Site Materials C or Products None 

NFIRS–2 Revision 01/01/07 

Arson report attached 

Police report attached 

Coroner report attached 

Other reports attached 

Local Use 

Pre-Fire Plan Available 

Some of the information presented in this report may be 

based upon reports from other agencies: 

Incident Number 

1 

2 

3 Involved in ignition and burned 

Not involved in ignition, but burned 

Mobile Property Involved H1 None 

Involved in ignition, but did not burn 

On-site material (2) 

On-site material (3) 

On-site material (1) 

1 Bulk storage or warehousing 2 Processing or manufacturing 3 Packaged goods for sale 

4 Repair or service U Undetermined

1 Bulk storage or warehousing 2 Processing or manufacturing 3 Packaged goods for sale 

4 Repair or service U Undetermined

1 Bulk storage or warehousing 2 Processing or manufacturing 3 Packaged goods for sale 

4 Repair or service U Undetermined

On-Site Materials 

Storage Use 

NFIRS–2 Fire OMB 1660-0069 

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NFIRS-2 

Paperwork burden for this form (NFIRS Version 5.0 Modules 1-12 (Electronic)) is estimated to average 27 minutes per response. The burden estimate includes 

the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and submitting the form. You 

are not required to respond to this collection of information unless a valid OMB control number is displayed in the upper right corner of this form. Send 

comments regarding the accuracy of the burden estimate and any suggestions for reducing the burden to: Information Collection Management, Department of 

Homeland Security, Federal Emergency Management Agency, 500 C Street, SW, Washington, DC 20472. Paperwork Reduction Project (1660-0069) 

NOTE: Do not send your completed form to this address. 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Number of stories w/significant damage 

(25 to 49% flame damage) 

Number of stories w/minor damage 

(1 to 24% flame damage) 

Number of stories w/heavy damage 

(50 to 74% flame damage) 

Number of stories w/extreme damage 

(75 to 100% flame damage) 

Number of Stories Damaged by Flame J3 

Count the roof as part of the highest story. 

Story of 

fire origin 

Below grade 

Fire Origin J1 

Confined to room of origin 

Confined to floor of origin 

Confined to building of origin 

Beyond building of origin 

Fire Spread J2 

2 

3 

4 

5 

K1 

Type of Material Contributing Most 

to Flame Spread 

K2 

K 

Item contributing most to flame spread 

Type of material contributing 

most to flame spread Required only if item 

contributing code is 00 or <70. 

Check if no flame spread OR if 

same as Material First Ignited (Block D4, 

Fire Module) OR if unable to determine. 

Skip to 

Section L 

NFIRS–3 Revision 01/01/07 

M4 

Required if system operated. 

Number of sprinkler heads operating 

Presence of Automatic Extinguishing System 

Complete rest of 

Section M 

None Present 

Present 

M1 N 

U 

OR 

BY 

Main Floor Size I4 

, , Total square feet 

Width in feet 

, Length in feet 

, 

Detector Failure Reason L6 

Required if detector failed to operate. 

Power failure, shutoff, or disconnect 

Improper installation or placement 

Defective 

Lack of maintenance, includes 

not cleaning 

Battery missing or disconnected 

Battery discharged or dead 

Other 

Undetermined 

1 

2 

3 

4 

5 

6 

0 

U 

Detector Type L2 

Smoke 

Heat 

Combination smoke and heat 

Sprinkler, water flow detection 

More than one type present 

Other 

Undetermined 

1 

2 

3 

4 

5 

0 

U 

Detector Power Supply L3 

Battery only 

Hardwire only 

Plug-in 

Hardwire with battery 

Plug-in with battery 

Mechanical 

Multiple detectors & power 

supplies 

Other 

Undetermined 

1 

2 

3 

4 

5 

6 

7 

0 

U 

Detector Effectiveness L5 Required if detector operated. 

Alerted occupants, occupants responded 

Alerted occupants, occupants failed 

to respond 

There were no occupants 

Failed to alert occupants 

Undetermined 

1 

2 

3 

4 

U 

Type of Automatic Extinguishing System M2 

1 

2 

3 

4 

5 

6 

7 

0 

U 

Wet-pipe sprinkler 

Dry-pipe sprinkler 

Other sprinkler system 

Dry chemical system 

Foam system 

Halogen-type system 

Carbon dioxide (CO2) system 

Other special hazard system 

Undetermined 

Required if fire was within designed range of AES. 

System shut off 

Not enough agent discharged 

Agent discharged but did not 

reach fire 

Wrong type of system 

Fire not in area protected 

System components damaged 

Lack of maintenance 

Manual intervention 

Other 

Undetermined 

M5 

Required if system failed or not effective. 

Reason for Automatic 

Extinguishing System Failure 

1 

2 

3 

4 

5 

6 

7 

8 

0 

U 

Detector Operation L4 

1 

2 

3 

U 

Fire too small to activate 

Operated 

Failed to operate 

Complete 

Block L5 

Undetermined 

Complete 

Block L6 

Total number of stories at or 

above grade. 

Building 

Height 

Total number of stories 

below grade. 

I3 

Count the roof as part of the 

highest story. Under construction 

In normal use 

Idle, not routinely used 

Under major renovation 

Vacant and secured 

Vacant and unsecured 

Being demolished 

Other 

Undetermined 

Building Status I2 

1 

2 

3 

4 

5 

6 

7 

0 

U 

Operated/effective (go to M4) 

Operated/Not effective (go to M4) 

Fire too small to activate 

Failed to operate (go to M5) 

Other 

Undetermined 

Operation of Automatic M Extinguishing System 3 

Required if fire was within designed range. 

1 

2 

3 

4 

0 

U 

I1 

Structure Type 

Enclosed building 

Portable/Mobile structure 

Open structure 

Air-supported structure 

Tent 

Open platform (e.g., piers) 

Underground structure (work areas) 

Connective structure (e.g., fences) 

Other type of structure 

If fire was in an enclosed building or a 

portable/mobile structure, complete the 

rest of this form. 

1 

2 

3 

4 

5 

6 

7 

8 

0 

None Present 

Presence of Detectors L1 

Skip to 

Section M 

Present 

N 

1 

(In area of the fire) 

U Undetermined 

Number of Sprinkler 

Heads Operating 

If fire spread was confined to object of origin, 

do not check a box (Ref. Block D3, Fire Module). 

Undetermined 

2 Partial System Present 

1 

NFIRS–3 

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NFIRS-3 

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are not required to respond to this collection of information unless a valid OMB control number is displayed in the upper right corner of this form. Send 

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O Primary Area of Body Injured 

Head 

Neck and shoulder 

Thorax 

Abdomen 

Spine 

Upper extremities 

Lower extremities 

Internal 

Multiple body parts 

1 

2 

3 

4 

5 

6 

7 

8 

9 Primary apparent symptom 

Look up a code only if the symptom is NOT found above 

Smoke only, asphyxiation 

Burns and smoke inhalation 

Burns only 

Cut, laceration 

Strain or sprain 

Shock 

Pain only 

01 

11 

12 

21 

33 

96 

98 

N Primary Apparent Symptom 

Casualty Number 

Casualty C Number 

Human Factors 

Contributing to Injury J 

Asleep 

Unconscious 

Possibly impaired by alcohol 

Possibly impaired by other drug 

Possibly mentally disabled 

Physically disabled 

Physically restrained 

Unattended person 

Check all applicable boxes 

None 

Affiliation 

Civilian 

EMS, not fire department 

Police 

Other 

F 

1 

2 

3 

0 

Months (for infants) 

Age 

OR 

Date of Birth 

D Age or Date of Birth 

Month Day Year 

Date of Injury Time of Injury 

G Date and Time of Injury 

Month 

Midnight is 0000. 

Day Year Hour Minute 

E2 Ethnicity 

Hispanic or Latino 

Transported to emergency care facility 

P Disposition

NFIRS–4 Revision 01/01/07 

Remarks Local option 

Specific location at time of injury 

M5 Specific Location at Time of Injury 

Complete ONLY if casualty NOT in area of origin 

Below grade 

M3 

Story at start of incident 

Story at Start of Incident 

Complete ONLY if injury occurred INSIDE 

M2 General Location at Time of Injury 

In area of fire origin 

In building, but not in area 

Outside, but not in area 

Skip to 

Section N 

Skip to

Block M5 

1 

2 

3 

Story where injury occurred, if 

different from M3 Below grade 

M4 Story Where Injury Occurred 

A Delete 

Change 

Factors Contributing 

to Injury 

K 

Contributing factor (1) 

Contributing factor (2) 

Contributing factor (3) 

None 

Enter up to three contributing factors 

M1 1 

2 

3 

4 

0 

U 

In area of origin and not involved 

Not in area of origin and not involved 

Not in area of origin, but involved 

In area of origin and involved 

Other location 

Undetermined 

1 

2 

3 

4 

5 

6 

7 

8 

White 

Black, African American 

Am. Indian, Alaska Native 

Asian 

Native Hawaiian, Other 

Pacific Islander 

Other, multiracial 

E Race 1 

1 

2 

3 

4 

5 

0 

Severity H 

Minor 

Moderate 

Severe 

Life threatening 

Death 

Undetermined 

1 

2 

3 

4 

5 

U 

Activity When Injured L 

Escaping 

Rescue attempt 

Fire control 

Return to fire before control 

Return to fire after control 

Sleeping 

Unable to act 

Irrational act 

Other 

Undetermined 

1 

2 

3 

4 

5 

6 

7 

8 

0 

U 

First Name Last Name Suffix 

B Injured Person 

1 Male 

MI 

2 Female 

Cause of Injury 

Exposed to fire products including flame 

heat, smoke, and gas 

Exposed to toxic fumes other than smoke 

Jumped in escape attempt 

Fell, slipped, or tripped 

Caught or trapped 

Structural collapse 

Struck by or contact with object 

Overexertion or strain 

Multiple causes 

Other 

Undetermined 

1 

2 

3 

4 

5 

6 

7 

8 

9 

0 

U 

FDID Incident Date Station Exposure 

MM DD YYYY 

State 

1 

Incident Number 

I 

Location at Time of Incident 

U Undetermined 

0 Non Hispanic or Latino 

U Undetermined 

Gender 

NFIRS–4 Civilian 

Fire Casualty OMB 1660-0069 

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NOTE: Do not send your completed form to this address. 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

A Delete 

Change FDID Incident Date Station Exposure 

MM DD YYYY 

State Incident Number 

NFIRS–5 Fire 

Service Casualty OMB 1660-0069 

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*Paperwork Burden 

Notice on Back 

First Name Last Name Suffix 

Injured Person B Identification Number 

MI 

Male 

Female 

1 

2 

Career 

Volunteer 

1 

2 

Casualty Number C 

Casualty Number 

In years 

OR 

Date of Birth 

D Age or Date of Birth 

Month Day Year 

Age Date of Injury Time of Injury 

E Date and Time of Injury Midnight is 0000. 

Month Day Year Hour Minute 

Responses F 

Number of prior responses 

during past 24 hours 

G1 Usual Assignment 

Suppression 

EMS 

Prevention 

Training 

Maintenance 

Communications 

Administration 

Fire investigation 

Other 

1 

2 

3 

4 

5 

6 

7 

8 

0 

G2 

Physical Condition Just Prior to Injury 

Rested 

Fatigued 

Ill or injured 

1 

2 

4 

Other 

Undetermined 

0 

U 

G4 Taken To 

Hospital 

Doctor’s office 

Morgue/Funeral home 

Residence 

Station or quarters 

Other 

1 

4 

5 

6 

7 

0 

Not transported 

Report only, including exposure 

First aid only 

Treated by physician (no lost time) 

Moderate (lost time) 

Severe (lost time) 

Life threatening (lost time) 

Death 

Severity G3 

1 

2 

3 

4 

5 

6 

7 

Activity at Time of Injury G5 

Activity at time of injury 

H1 

Primary apparent symptom 

Primary Apparent Symptom Cause of Firefighter Injury 

Cause of injury 

I1 

Object involved in injury 

Object Involved 

in Injury I3 None 

Primary injured body part 

H2 

Primary Part of Body Injured None 

Contributing factor 

Factor Contributing to Injury I2 None 

Where Injury Occurred J1 

En route to FD location 

At FD location 

En route to incident scene 

En route to medical facility 

At scene in structure 

At scene outside 

At medical facility 

Returning from incident 

Returning from med facility 

Other 

1 

2 

3 

4 

5 

6 

7 

8 

9 

0 

U Undetermined 

Specific Location Where 

Injury Occurred 

Complete 

Block J4 

65 In aircraft 

64 In boat, ship, or barge 

63 In rail vehicle 

61 In motor vehicle 

54 In sewer 

53 In tunnel 

49 In structure 

45 In attic 

36 In water 

35 In well 

34 In ravine 

33 In quarry or mine 

32 In ditch or trench 

31 In open pit 

28 On steep grade 

27 On fire escape/outside stairs 

00 Other 

UU Undetermined 

J3 

Suppression vehicle 

EMS vehicle 

Other FD vehicle 

Non-FD vehicle 

Vehicle Type J4 

1 

2 

3 

4 

Complete ONLY if 

Specific Location code 

is >60 

Remarks 

J2 

Story Where Injury Occurred 

Story of injury Below grade 

Check this box and enter the story if the 

injury occurred inside or on a structure 1 26 On vertical surface or ledge 

25 On ground ladder 

24 On aerial ladder or in basket 

23 On roof 

If protective equipment failed and 

was a factor in this injury, please 

complete the other side of this 

form. 

2 Injury occurred outside 22 Outside at grade NFIRS–5 Revision 01/01/07 
*PAPERWORK BURDEN DISCLOSURE NOTICE 

NFIRS-5 

Paperwork burden for this form (NFIRS Version 5.0 Modules 1-12 (Electronic)) is estimated to average 27 minutes per response. The burden estimate includes 

the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and submitting the form. You 

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comments regarding the accuracy of the burden estimate and any suggestions for reducing the burden to: Information Collection Management, Department of 

Homeland Security, Federal Emergency Management Agency, 500 C Street, SW, Washington, DC 20472. Paperwork Reduction Project (1660-0069) 

NOTE: Do not send your completed form to this address. 
 

Equipment NFIRS–5 K1 Did protective equipment fail and contribute to the injury? Yes Y 

Sequence Fire Service

Please complete the remainder of this form ONLY if you answer YES. Number No N Casualty 

Protective Equipment Item Protective Equipment Problem K2 K3 

Check one box to indicate the main problem that occurred. 

Head or Face Protection Coat, Shirt, or Trousers 11 Burned 

11 Helmet 21 Protective coat 12 Melted 12 Full face protector 22 Protective trousers

13 Partial face protector 23 Uniform shirt 21 Fractured, cracked or broken 14 Goggles/eye protection 24 Uniform T-shirt

15 Hood 25 Uniform trousers 22 Punctured 

16 Ear protector 26 Uniform coat or jacket

17 Neck protector 27 Coveralls 23 Scratched

10 Other 28 Apron or gown

24 Knocked off
 

Boots or Shoes
 

20 Other 

25 Cut or ripped

31 Knee length boots with steel baseplate and steel toes 

32 Knee length boots with steel toes only 31 Trapped steam or hazardous gas

33 3/4 length boots with steel baseplate and steel toes 

34 32 Insufficient insulation 3/4 length boots with steel toes only

35 Boots without steel baseplate and steel toes 33 Object fell in or onto equipment item 36 Safety shoes with steel baseplate and steel toes

37 Safety shoes with steel toes only 41 Failed under impact 38 Non-safety shoes

30 Other 42 Face piece or hose detached 

Respiratory Protection 

43 Exhalation valve inoperative or damaged

41 SCBA (demand) open circuit

42 SCBA (positive pressure) open circuit 44 Harness detached or separated

43 SCBA closed circuit 

44 Not self-contained 45 Regulator failed to operate

45 Cartridge respirator 46 Regulator damaged by contact 46 Dust or particle mask

40 Other 47 Problem with admissions valve 

Hand Protection 

48 Alarm failed to operate

51 Firefighter gloves with wristlets

52 Firefighter gloves without wristlets 49 Alarm damaged by contact

53 Work gloves 

54 HazMat gloves 51 Supply cylinder or valve failed to operate

55 Medical gloves 52 Supply cylinder/valve damaged by contact 50 Other
 

Special Equipment
 53 Supply cylinder—insufficient air/oxygen 

61 Proximity suit for entry 94 Did not fit properly

62 Proximity suit for non-entry 

63 Totally encapsulated, reusable chemical suit 95 Not properly serviced or stored prior to use

64 Totally encapsulated, disposable chemical suit 

65 Partially encapsulated, reusable chemical suit 96 Not used for designed purpose 

66 Partially encapsulated, disposable chemical suit 97 Not used as recommended by manufacturer 67 Flash protection suit 

68 Flight or jump suit 00 Other equipment problem 69 Brush suit 

71 Exposure suit UU Undetermined

72 Self-contained underwater breathing apparatus (SCUBA) Equipment Manufacturer, Model and Serial 73 Life preserver K4 Number 74 Life belt or ladder belt 

Was the failure of more 75 Personal alert safety system (PASS) than one item of protective 76 Radio distress device Manufacturer equipment a factor in the 77 Personal lighting injury? If so, complete an 78 Fire shelter or tent additional page of this Model 

79 Vehicle safety belt form for each piece of

70 Special equipment, other failed equipment. Serial Number 

00 Protective equipment, other NFIRS–5 Revision 05/01/03
*PAPERWORK BURDEN DISCLOSURE NOTICE 

NFIRS-5 

Paperwork burden for this form (NFIRS Version 5.0 Modules 1-12 (Electronic)) is estimated to average 27 minutes per response. The burden estimate includes 

the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and submitting the form. You 

are not required to respond to this collection of information unless a valid OMB control number is displayed in the upper right corner of this form. Send 

comments regarding the accuracy of the burden estimate and any suggestions for reducing the burden to: Information Collection Management, Department of 

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NOTE: Do not send your completed form to this address. 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1 

N EMS 

Disposition 

1 

2 

3 

4 

0 

FD transport to ECF 

Non-FD transport 

Non-FD trans/FD attend 

Non-emergency transfer 

Other 

NFIRS–6 Revision 01/01/07 

Time of Patient Transfer 

C Date/Time 

Time Arrived at Patient 

Month Day Year Hour/Min 

M Patient Status 

Improved 

Remained same 

Worsened 

1 

2 

3 

Pulse on transfer 

Check if: 

H1 

Body Site of Injury H2 Injury Type 

List up to five body sites List one injury type for each body site listed under H1 

Airway insertion 

Anti-shock trousers 

Assist ventilation 

Bleeding control 

Burn care 

Cardiac pacing 

Cardioversion (defib) manual 

Chest/Abdominal thrust 

CPR 

Cricothyroidotomy 

Defibrillation by AED 

EKG monitoring 

Extrication 

Intubation (EGTA) 

Intubation (ET) 

IO/IV therapy 

Medications therapy 

Oxygen therapy 

OB care/delivery 

Prearrival instructions 

Restrain patient 

Spinal immobilization 

Splinted extremities 

Suction/Aspirate 

Other 

Check all applicable boxes 

A Delete 

Change 

Age OR 

Month Day Year 

Months (for infants) 

E1 Age or Date of Birth 

E2 

Gender 

1 Male 2 Female 

Other 

Factors 

Accidental 

Self-inflicted 

Inflicted, not self 

None 

1 

2 

3 

G2 

If an illness, not an 

injury, skip G2 and 

go to H3 

J Safety 

Equipment 

Safety/Seat belts 

Child safety seat 

Airbag 

Helmet 

Protective clothing 

Flotation device 

Other 

Undetermined 

1 

2 

3 

4 

5 

6 

0 

U 

Used or deployed by patient. 

Check all applicable boxes. 

Human Factors 

Contributing to Injury 

Asleep 

Unconscious 

Possibly impaired by alcohol 

Possibly impaired by drug 

Possibly mentally disabled 

Physically disabled 

Physically restrained 

Unattended person 

Check all applicable boxes 

G1 

Highest Level of Care L Provided On Scene 2 

1 

2 

3 

4 

0 

First Responder 

EMT-B (Basic) 

EMT-I (Intermediate) 

EMT-P (Paramedic) 

Other provider 

1 

2 

3 

4 

5 

6 

7 

8 

01 

02 

03 

04 

05 

06 

07 

08 

09 

10 

11 

12 

13 

14 

15 

16 

17 

18 

19 

20 

21 

22 

23 

24 

00 

Initial Arrest Rhythm 

1 

0 

U 

V-Fib/V-Tach 

Other 

Undetermined 

K Cardiac Arrest 

Check all applicable boxes 

If pre-arrival arrest, was it: 

1 Pre-arrival arrest? 

Witnessed? 

Bystander CPR? 

1 

2 

2 Post-arrival arrest? 

Ethnicity F2 

Hispanic or Latino 

F1 

Race 

White 

Black, African American 

Am. Indian, Alaska Native 

Asian 

Other, multiracial 

Undetermined 

1 

2 

3 

4 

0 

U 

Use a separate form for each patient 

Number of Patients Patient Number B 

Provider Impression/Assessment 

Hypovolemia 

Inhalation injury 

Obvious death 

OD/Poisoning 

Pregnancy/OB 

Respiratory arrest 

Respiratory distress 

Seizure 

Chest pain 

Diabetic symptom 

Do not resuscitate 

Electrocution 

General illness 

Hemorrhaging/Bleeding 

Hyperthermia 

Hypothermia 

Abdominal pain 

Airway obstruction 

Allergic reaction 

Altered LOC 

Behavioral/Psych 

Burns 

Cardiac arrest 

Cardiac dysrhythmia 

10 

11 

12 

13 

14 

15 

16 

17 

18 

19 

20 

21 

22 

23 

24 

25 

26 

27 

28 

29 

30 

31 

32 

33 

Sexual assault 

Sting/Bite 

Stroke/CVA 

Syncope 

Trauma 

Other 

34 

35 

36 

37 

38 

00 

D Check one box only 

First Responder 

EMT-B (Basic) 

EMT-I (Intermediate) 

EMT-P (Paramedic) 

Other provider 

No Training 

L1 

1 

2 

3 

4 

0 

N 

Initial Level of 

Provider 

H3 

Cause of 

Illness/Injury 

Cause of illness/Injury 

FDID Incident Date Station Exposure 

MM DD YYYY 

State 

1 

Incident Number 

I Procedures Used 

Check if same date 

as Alarm date 

None 

None/no patient or refused treatment 

2 Non Hispanic or Latino 

None No treatment 

None 

2 No pulse on transfer 

Not transported 

5 Native Hawaiian, Other 

Pacific Islander 

NFIRS–6 EMS OMB 1660-0069 

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are not required to respond to this collection of information unless a valid OMB control number is displayed in the upper right corner of this form. Send 

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Equipment involved in release 

Year 

M Equipment Involved 

in Release 

Brand 

Model 

Serial # 

A Delete 

Change 

I If fire or explosion is involved with a 

release, which occurred first? 

Ignition 

Release 

1 Undetermined 

2 

U 

NFIRS–7 

Revision 01/01/07

 Complete the remainder 

of this form only for the 

first hazardous material 

involved in this incident. 

F2 Population Density 

Urban 

Suburban 

Rural 

1 

2 

3 

Factor contributing to release (2) 

Factors Contributing to Release K 

Factor contributing to release (3) 

Enter up to three contributing factors 

Factor contributing to release (1) 

L Factors Affecting Mitigation 

Factor or impediment (2) 

Factor or impediment (3) 

Enter up to three factors or impediments that affected the 

mitigation of the incident. 

Factor or impediment (1) 

Mobile property type 

License plate number State 

Year 

Mobile property make 

Model 

Mobile Property Involved in N Release 

None 

DOT number/ ICC number 

Primary action taken (1) 

Additional action taken (2) 

Additional action taken (3) 

HazMat Actions Taken H Enter up to three actions taken 

G3 Estimated Number of 

People Evacuated 

, 

G1 Area Affected 

Blocks 

Square feet 

Square miles 

Enter measurement 

1 

2 

3 

, 

G Area Evacuated 2 

Blocks 

Square feet 

Square miles 

1 

2 

3 

G4 Estimated Number of 

Buildings Evacuated 

, 

C2 Estimated Container Capacity 

, , Capacity: by volume or weight 

C3 Units: Capacity Check one box 

Enter Code 

VOLUME 

Ounces 

Gallons 

Barrels: 42 gal. 

Liters 

Cubic feet 

Cubic meters 

11 

12 

13 

14 

15 

16 

WEIGHT 

MICRO UNITS 

Enter Code 

Ounces 

Pounds 

Grams 

Kilograms 

21 

22 

23 

24 

C1 Container 

Type 

More hazardous 

materials? Use 

additional sheets. 

Container Type D2 Units: Released Check one box 

WEIGHT 

Ounces 

Pounds 

Grams 

Kilograms 

21 

22 

23 

24 

VOLUME 

Ounces 

Gallons 

Barrels: 42 gal. 

Liters 

Cubic feet 

Cubic meters 

11 

12 

13 

14 

15 

16 

Physical State

When Released 

Solid 

Liquid 

Gas 

Undetermined 

1 

2 

3 

U 

E1 

P 

Deaths Injuries 

E2 

Released Into 

Released into 

F1 Released From 

Inside/on structure 

Story of release 

Below grade 

Outside of structure 

Check all applicable boxes 

1 

2 

, , 

D1 Estimated Amount Released 

Amount released: by volume or weight 

J Cause of Release 

Intentional 

Unintentional release 

Container/Containment failure 

Act of nature 

Cause under investigation 

Cause undetermined after 

investigation 

1 

2 

3 

4 

5 

U 

HazMat Disposition O 

Completed by fire service only 

Completed w/fire service present 

Released to local agency 

Released to county agency 

Released to State agency 

Released to Federal agency 

Released to private agency 

Released to property owner or 

manager 

1 

2 

3 

4 

5 

6 

7 

8 

B UN Number CAS Registration Number 

HazMat ID DOT Hazard 

Classification 

Chemical 

Name 

Enter 

measurement 

, 

FDID Station Exposure Haz No. Incident Date 

MM DD YYYY 

State Incident Number 

HazMat Civilian Casualties 

None 

None 

None 

None 

None 

MICRO UNITS 

NFIRS–7 HazMat OMB 1660-0069 

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NFIRS-7 

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are not required to respond to this collection of information unless a valid OMB control number is displayed in the upper right corner of this form. Send 

comments regarding the accuracy of the burden estimate and any suggestions for reducing the burden to: Information Collection Management, Department of 

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NOTE: Do not send your completed form to this address. 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NFIRS–8 Revision 01/01/07 

Delete 

Change 

Day Year 

Age in Years 

OR 

Date of Birth 

Age or Date of Birth L3 

Month 

Person Responsible for Fire L1 

Identified person caused fire 

Unidentified person caused fire 

Fire not caused by person 

1 

2 

3 

If person identified, complete the rest of Section L. 

Male 

Female 

Gender of Person Involved L2 

1 

2 

Area Type C 

Rural, farms >50 acres 

Urban (heavily populated) 

Rural/Urban or suburban 

Urban-wildland interface area 

1 

2 

3 

4 

A 

F Mobile Property Type 

Equipment Involved G in Ignition 

Type of Right-of-Way 

Required if less than 100 feet. 

Feet 

M 

Horizontal distance 

from right-of-way 

Type of right-of-way 

Activity of Person Involved L4 

Activity of Person Involved 

N Fire Behavior 

These optional descriptors refer to observations 

made at the point of initial attack. 

Elevation 

Feet 

Relative position on slope 

Aspect 

Flame length 

Feet 

Rate of spread 

Chains per Hour 

Heat Source E 

Tax paying 

Non-tax paying 

City, town, village, local 

County or parish 

State or province 

Federal 

Federal Agency Code 

Foreign 

Military 

Other 

Private 

Public 

Property Management 

1 

2 

3 

4 

5 

6 

7 

8 

0 

U Undetermined % 

% 

% 

% 

% 

% 

% 

% 

% 

% 

Ownershi % Total Acres Burned p 

Indicate the percent of the total acres burned for each ownership type then check the ONE box to identify the property ownership at the origin of the fire. If the ownership at origin is Federal, 

enter the Federal Agency Code. 

J K NFDRS Fuel Model at Origin 

Enter the code and the descriptor corresponding 

to the NFDRS Fuel Model at Origin. 

Identify up to 3 crops if any crops were burned. 

Primary Crops Burned I4 

Crop 1 

Crop 2 

Crop 3 

D4 Fire Suppression Factors 

#1 

#2 

#3 

Enter 

up to 

three 

factors 

H Weather Information 

F° 

Air Temperature 

Relative Humidity 

% 

Check if 

Wind Speed (mph) negative 

Weather Type Wind Direction 

Fuel Moisture Fire Danger Rating 

NFDRS Weather Station ID 

% 

I1 

Number of buildings that were 

ignited in Wildland fire. 

None 

Number of Buildings Ignited 

I2 

Number of buildings that were threatened by 

Wildland fire but were not involved. 

None 

Number of Buildings Threatened 

• Latitude Longitude 

Section 

OR 

B Alternate Location Specification 

Subsection Meridian 

•

Factors Contributing 

to Ignition 

#1 #2 

D3 D Wildland Fire Cause 1 

Natural source 

Equipment 

Smoking 

Open/Outdoor fire 

Debris/Vegetation burn 

Structure (exposure) 

Incendiary 

Misuse of fire 

Other 

Undetermined 

1 

2 

3 

4 

5 

6 

7 

8 

0 

U 

Asleep 

Possibly impaired by alcohol or drugs 

Unattended person 

Possibly mentally disabled 

Physically disabled 

Multiple persons involved 

Age was a factor 

Human Factors Contributing 

to Ignition

Check as many boxes as are applicable. 

D2 

1 

2 

3 

4 

5 

6 

7 

, 

I3 

, 

Total Acres Burned 

•

FDID Incident Date Station Exposure 

MM DD YYYY 

State Incident Number 

None 

None 

None 

None 

None 

North 

South 

East 

West • Township Range 

Enter Latitude/Longitude OR Township/Range/Section/Subsection 

Meridian if Section B on the Basic Module is not completed. 

None 

NFIRS–8 

Wildland Fire OMB 1660-0069 

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NFIRS-8 

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comments regarding the accuracy of the burden estimate and any suggestions for reducing the burden to: Information Collection Management, Department of 

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Delete 

NFIRS–9 Revision 01/01/07 

Change 

Dates and Times Apparatus Use Actions Taken 

of 

Number 

People 

Check if same date as Alarm date on 

the Basic Module (Block E1). 

Month Day Year Hour/Min 

Sent 

X 

Check ONE box for each 

apparatus to indicate its main 

use at the incident. 

Aircraft 

Marine Equipment 

Support Equipment 

Medical and Rescue 

Other 

Ground Fire Suppression 

11 Engine 

12 Truck or aerial 

13 Quint 

14 Tanker and pumper combination 

16 Brush truck 

17 ARFF (aircraft rescue and firefighting) 

10 Ground fire suppression, other 

Heavy Ground Equipment 

21 Dozer or plow 

22 Tractor 

24 Tanker or tender 

20 Heavy ground equipment, other 

41 Aircraft: fixed-wing tanker 

42 Helitanker 

43 Helicopter 

40 Aircraft, other 

51 Fire boat with pump 

52 Boat, no pump 

50 Marine equipment, other 

61 Breathing apparatus support 

62 Light and air unit 

60 Support apparatus, other 

71 Rescue unit 

72 Urban search and rescue unit 

73 High-angle rescue unit 

75 BLS unit 

76 ALS unit 

70 Medical and rescue unit, other 

91 Mobile command post 

92 Chief officer car 

93 HazMat unit 

94 Type I hand crew 

95 Type II hand crew 

99 Privately owned vehicle 

00 Other apparatus/resources 

More apparatus? 

Use additional 

sheets. 

Suppression 

EMS 

Other 

Dispatch 

Arrival 

Clear 

Suppression 

EMS 

Other 

ID 

Type 

2 

Suppression 

EMS 

Other 

ID 

Type 

3 

Suppression 

EMS 

Other 

ID 

Type 

4 

Suppression 

EMS 

Other 

ID 

Type 

5 

Suppression 

EMS 

Other 

ID 

Type 

6 

Suppression 

EMS 

Other 

ID 

Type 

7 

Suppression 

EMS 

Other 

ID 

Type 

8 

Suppression 

EMS 

Other 

ID 

Type 

9 

Apparatus or Resource Type 

A 

Apparatus or 

Resources 

ID 

Type 

1 

Use codes listed below 

B 

Dispatch 

Arrival 

Clear 

Dispatch 

Arrival 

Clear 

Dispatch 

Arrival 

Clear 

Dispatch 

Arrival 

Clear 

Dispatch 

Arrival 

Clear 

Dispatch 

Arrival 

Clear 

Dispatch 

Arrival 

Clear 

Dispatch 

Arrival 

Clear 

FDID Incident Date Station Exposure 

MM DD YYYY 

State Incident Number 

NN None 

UU Undetermined 

Midnight is 0000 

List up to 4 actions for each 

apparatus. 

NFIRS–9 Apparatus

or Resources OMB 1660-0069 

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are not required to respond to this collection of information unless a valid OMB control number is displayed in the upper right corner of this form. Send 

comments regarding the accuracy of the burden estimate and any suggestions for reducing the burden to: Information Collection Management, Department of 

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Delete 

Change 

of 

Number 

People X 

Check if same date as Alarm date on 

the Basic Module (Block E1). 

Sent 

Day Hour/Min 

Dates and Times 

Month 

Apparatus or 

Resources 

Year 

Actions Taken 

Check ONE box for each 

apparatus to indicate its main 

use at the incident. 

Apparatus Use 

List up to 4 actions for 

each apparatus and 

each personnel. 

Suppression 

EMS 

Other Type 

ID 

Action 

Taken 

Action 

Taken 

Action 

Taken 

Rank or 

Grade 

Personnel Name 

ID 

Attend 

X 

Action 

Taken 

3 Sent 

Suppression 

EMS 

Type Other 

ID 

Action 

Taken 

Action 

Taken 

Action 

Taken 

Rank or 

Grade 

Personnel Name 

ID 

Attend 

X 

Action 

Taken 

2 Sent 

Suppression 

EMS 

Type Other 

Dispatch 

Arrival 

Clear 

ID 

Action 

Taken 

Action 

Taken 

Action 

Taken 

Rank or 

Grade 

Personnel Name 

ID 

Attend 

X 

Action 

Taken 

1 Sent 

A 

B 

Dispatch 

Arrival 

Clear 

Dispatch 

Arrival 

Clear 

FDID Incident Date Station Exposure 

MM DD YYYY 

State Incident Number 

Midnight is 0000 

NFIRS–10 Personnel OMB 1660-0069 

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NFIRS-10 

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Homeland Security, Federal Emergency Management Agency, 500 C Street, SW, Washington, DC 20472. Paperwork Reduction Project (1660-0069) 

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A Delete 

Change 

Investigation open 

Investigation closed 

Investigation inactive 

1 

2 

3 

C Case Status 

E Suspected Motivation Factors Check up to three factors 

Extortion 

Labor unrest 

Insurance fraud 

Intimidation 

Void contract/lease 

Foreclosed property 

11 

12 

13 

14 

15 

16 

21 Personal 

Hate crime 

Institutional 

Societal 

Protest 

Civil unrest 

Fireplay/Curiosity 

22 

23 

24 

31 

32 

41 

Vanity/Recognition 

Thrills 

Attention/Sympathy 

Sexual excitement 

Homicide 

Suicide 

Domestic violence 

42 

43 

44 

45 

51 

52 

53 

Burglary 

Homicide concealment 

Burglary concealment 

Auto theft concealment 

Destroy records/evidence 

Other suspected motivation 

Unknown motivation 

54 

61 

62 

63 

64 

00 

UU 

F Apparent Group Involvement 

Terrorist group 

Gang 

Anti-government group 

Outlaw motorcycle organization 

Organized crime 

Racial/Ethnic hate group 

Religious hate group 

Sexual preference hate group 

Other group 

Unknown 

1 

2 

3 

4 

5 

6 

7 

8 

0 

U 

Check up to three factors 

J Property Ownership 

Private 

City, town, village, local 

County or parish 

State or province 

Federal 

Foreign 

Military 

Other 

1 

2 

3 

4 

5 

6 

7 

0 

B Agency Referred To None 

Agency Name Their case number 

G1 Entry Method 

Entry Method 

I Other Investigative Information 

Check all that apply 

Bottle (glass) 

Bottle (plastic) 

Jug 

H Incendiary Devices 

Select one from each category 

11 

12 

13 

L Laboratory Used 

Local 

State 

1 

2 

ATF 6 Private 

FBI 

3 

4 

Other 

Federal 

5 

Check all that apply 

D Availability of Material First Ignited 

1 

2 

U 

Transported to scene 

Available at scene 

Unknown 

Closed with arrest 

Closed with exceptional 

clearance 

4 

5 

Code violations 

Structure for sale 

Structure vacant 

Other crimes involved 

Illicit drug activity 

Change in insurance 

Financial problem 

Criminal/Civil actions pending 

1 

2 

3 

4 

5 

6 

7 

8 

Pressurized container 

Can (not gas or fuel) 

Gasoline or fuel can 

14 

15 

16 

Box 

Other Container 

Unknown 

17 

00 

UU 

CONTAINER No container 

Wick or fuse 

Candle 

Cigarette and matchbook 

Electronic component 

Mechanical device 

Remote control 

11 

12 

13 

14 

15 

16 

Road flare/fuse 

Chemical component 

Trailer/Streamer 

Open flame source 

Other delay device 

Unknown 

17 

18 

19 

20 

00 

UU 

IGNITION/DELAY DEVICE 

Ordinary combustibles 

Flammable gas 

Ignitable liquid 

Ignitable solid 

11 

12 

14 

15 

Pyrotechnic material 

Explosive material 

Other material 

Unknown 

16 

17 

00 

UU 

FUEL 

Initial Observations 

G2 

Extent of Fire Involvement on Arrival 

Extent of Fire Involvement 

1 

2 

3 

4 

Windows ajar 

Doors ajar 

Doors locked 

Doors unlocked 

5 

6 

7 

8 

Fire department forced entry 

Entry forced prior to FD arrival 

Security system activated 

Security system present

(not activated) 

K 

Check all that apply 

FDID Incident Date Station Exposure 

MM DD YYYY 

State 

NFIRS–11 Revision 01/01/07 

Incident Number 

No device 

None 

None 

None 

Number Prefix Street or Highway Street Type Suffix Their ORI 

Post Office Box Apt./Suite/Room City Their Federal Identifier (FID) 

State ZIP Code Agency phone number Their FDID 

NFIRS–11 Arson OMB 1660-0069 

Expires 04/30/2019 

*Paperwork Burden 

Notice on Back 
*PAPERWORK BURDEN DISCLOSURE NOTICE 

NFIRS-11 

Paperwork burden for this form (NFIRS Version 5.0 Modules 1-12 (Electronic)) is estimated to average 27 minutes per response. The burden estimate includes 

the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and submitting the form. You 

are not required to respond to this collection of information unless a valid OMB control number is displayed in the upper right corner of this form. Send 

comments regarding the accuracy of the burden estimate and any suggestions for reducing the burden to: Information Collection Management, Department of 

Homeland Security, Federal Emergency Management Agency, 500 C Street, SW, Washington, DC 20472. Paperwork Reduction Project (1660-0069) 

NOTE: Do not send your completed form to this address. 
M1 Subject Number 

Subject Number 

M2 Age or Date of Birth 

Age (in years) 

OR 

Month Day Year 

M3 Gender 

1 Male 2 Female

Disposition of Person Under 18 M8 

Complete this section

 if the person involved in 

the ignition of the fire 

was a child or Juvenile 

under the age of 18. 

Motivation/Risk Factors M7 

Mild curiosity about fire 

Moderate curiosity about fire 

Extreme curiosity about fire 

Diagnosed (or suspected) ADD/ADHD 

History of trouble outside school 

History of stealing or shoplifting 

History of physically assaulting others 

History of fireplay or firesetting 

Transiency 

Other 

Unknown 

1 

2 

3 

4 

5 

6 

7 

8 

9 

0 

U 

M5 Ethnicity 

Hispanic or Latino 

Family Type M6 

Single parent 

Foster parent(s) 

Two-parent family 

Extended family 

No family unit 

Other family type 

Unknown 

1 

2 

3 

4 

N 

0 

U 

N Remarks (local use) 

Race M4 

White 

Black, African American 

American Indian, Alaska 

Native 

Native Hawaiian, Other 

Pacific Islander 

1 

2 

3 

5 

Other, multiracial 

Undetermined 

0 

U 

Check only one of codes 1–3 

and then all others (4–9) 

that apply. 

Handled within department 

Released to parent/guardian 

Referred to other authority 

Referred to treatment/counseling program 

Arrested, charged as adult 

Referred to firesetter intervention program 

Other 

Unknown 

1 

2 

3 

4 

5 

6 

0 

U 

1 

A Delete 

FDID Incident Date Station Exposure Change

MM DD YYYY 

State Incident Number 

NFIRS–11 

Juvenile 

Firesetter 

0 Non Hispanic or Latino

Complete a separate Section M 

form for each juvenile. 

4 Asian
*PAPERWORK BURDEN DISCLOSURE NOTICE 

NFIRS-11 

Paperwork burden for this form (NFIRS Version 5.0 Modules 1-12 (Electronic)) is estimated to average 27 minutes per response. The burden estimate includes 

the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and submitting the form. You 

are not required to respond to this collection of information unless a valid OMB control number is displayed in the upper right corner of this form. Send 

comments regarding the accuracy of the burden estimate and any suggestions for reducing the burden to: Information Collection Management, Department of 

Homeland Security, Federal Emergency Management Agency, 500 C Street, SW, Washington, DC 20472. Paperwork Reduction Project (1660-0069) 

NOTE: Do not send your completed form to this address.