Title Page
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Audit Title
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Prepared by
GATES FIRE DISTRICT - PERSONAL INJURY / ILLNESS REPORT
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INFO OF INJURED PERSON
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Date:
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Phone:
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Height:
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Weight(lbs):
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Years with Dept. (If less than 1, choose 0):
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INJURY LOCATION
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Organization Name:
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Address:
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City:
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State:
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Zip Code:
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County:
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Location, Address, and Description:
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B: INJURED PERSON
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SSN:
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SEX:
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CAREER/VOLUNTEER:
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ID NUMBER:
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FIRST NAME:
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MI:
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LAST NAME:
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SUFFIX
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C: CASUALTY NUMBER
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CASUALTY NUMBER:
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D: AGE OR DATE OF BIRTH
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AGE:
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-OR-
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DOB:
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E: DATE AND TIME OF INJURY
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DATE/TIME:
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F: RESPONSE
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# OF PRIOR RESPONSES DURING THE PAST 24 HRS:
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G1: USUAL ASSIGNMENT:
- OTHER ASSIGNMENT
- FIRE SUPPRESSION (INCL HAZMAT, RESCUE, IC)
- EMS
- PREVENTION OR INSPECTION
- TRAINING
- MAINTENANCE
- COMMUNICATIONS
- ADMINISTRATION
- FIRE INVESTIGATION
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G2: PHYSICAL CONDITION JUST PRIOR TO INJURY:
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G3: SEVERITY:
- REPORT ONLY, INCLUDING EXPOSURE
- FIRST AID ONLY
- TREATED BY PHYSICIAN, NOT A LOST TIME INJURY
- MODERATE SEVERITY, LOST-TIME INJURY
- SEVERE, LOST-TIME INJURY
- LIFE THREATENING, LOST-TIME INJURY
- DEATH
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G4: TAKEN TO:
- TAKEN TO, OTHER
- HOSPITAL
- DOCTOR'S OFFICE
- MORGUE OR FUNERAL HOME
- RESIDENCE
- STATION OR QUARTERS
- NOT TRANSPORTED
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G5: ACTIVITY AT TIME OF INJURY:
- Driving or Riding Vehicle, Other
- Boarding Fire Department Vehicle
- Driving Fire Department Vehicle
- Tillering Fire Department Vehicle
- Riding Fire Department Vehicle
- Getting Off Fire Department Vehicle
- Driving/Riding Non-Fire Department Vehicle
- Boarding/Exiting Non-Fire Department Vehicle
- Operating Fire Department Apparatus, Other
- Operating Engine or Pumper
- Operating Aerial Ladder or Elevating Platform
- Operating EMS Vehicle
- Operating HazMat Vehicle
- Operating Rescue Vehicle
- Extinguishing Fire/Neutralizing Incident, Other
- Handling Charged Hose Lines
- Using Hand Extinguisher
- Operating Master Stream Devices
- Using Hand Tools in Extinguishment Activity
- Removing Power Lines
- Removing Flammable Liquids/Chemicals
- Shutting off Utilities, Gas Lines, Etc
- Suppression support, Other
- Forcible Entry
- Ventilation with Power Tools
- Ventilation with Hand Tools
- Salvage
- Overhauls
- Access/Egress, Other
- Carrying Ground Ladder
- Raising Ground Ladder
- Lowering Ground Ladder
- Climbing Ladder
- Scaling
- Escaping Fire/Hazard
- Moving/Lifting Patient with Carrying Device
- EMS/Rescue, Other
- Searching for Victim
- Rescuing Fire Victim
- Rescuing Non-Fire Victim
- Water Rescue
- Providing EMS Care
- Driving Operations
- Extraction with Power Tools
- Other Incident Scene Activity, Other
- Directing Traffic
- Catching Hydrant
- Laying Hose
- Moving Tools or Equipment Around Scene
- Picking-up Tools, Equipment, or Hose on scene
- Setting-up Lighting
- Operating Portable Pump
- Station Activity, Other
- Moving About Station Alarm Sounding
- Moving About Station, Normal Activity
- Station Maintenance
- Vehicle Maintenance
- Equipment Maintenance
- Physical Fitness Activity, Supervised
- Physical Fitness Activity, Unsupervised
- Incident Investigation, During Incident
- Incident Investigation, After Incident
- Inspection Activities
- Administrative Work
- Communications Work
- Undetermined
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H1: PRIMARY APPARENT SYMPTOM:
- Primary Apparent Symptom, Other
- Smoke Inhalation
- Hazardous Fumes Inhalation
- Breathing Difficulty or Shortness of Breath
- Burns and Smoke Inhalation
- Burn, Scald
- Burn, Chemical
- Burn, Electric
- Cut or Laceration
- Stab Wound/Puncture Wound: Penetration
- Gunshot Wound: Projectile Wound
- Contusion/Bruise, Minor Trauma
- Abrasion
- Dislocation
- Fracture
- Strain or Sprain
- Swelling
- Crushing
- Amputation
- Cardiac Symptoms
- Stroke
- Respiratory Arrest
- Sickness, Other
- Chills
- Fever
- Nausea
- Vomiting
- Numbness or Tingling, Paresthesia
- Paralysis
- Frostbite
- Miscarriage
- Eye Trauma, Avulsion
- Drowning
- Foreign Body Obstructions
- Electric Shock
- Poison
- Convulsion or Seizure
- Internal Trauma
- Hemorrhaging, Bleeding internally
- Disorientation
- Dizziness/Fainting/Weakness
- Exhaustion/Fatigue, including Heat Exhaustion
- Heat Stroke
- Dehydration
- Allergic Reaction, including Anaphylactic shock
- Drug Overdose
- Alcohol Impairment
- Emotional/Psychological Stress
- Mental Disorder
- Shock
- Unconscious
- Pain Only
- None
- Undetermined
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H2: PRIMARY AREA OF BODY INJURED:
- Head
- Neck & Shoulders
- Thorax
- Abdominal Area
- Spine
- Upper Extremities
- Lower Extremities
- Internal
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I1: CAUSE OF FIREFIGHTER INJURY:
- Cause of Injury, Other
- Fall
- Jump
- Slip/Trip
- Exposure to hazard
- Struck or Assaulted by Person/Animal/Object
- Contact with Object (firefighter moved into/onto)
- Overexertion/Strain
- Undetermined
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I2: FACTOR CONTRIBUTING TO INJURY:
- Collapse or Falling Object, Other
- Roof Collapse
- Wall Collapse
- Floor Collapse
- Ceiling Collapse
- Stair Collapse
- Falling Objects
- Cave-In (earth)
- Fire Development
- Fire Progress, including Smoky Conditions
- Backdraft
- Flashover
- Explosion
- Lost, Caught, Trapped, or Confined, Other
- Person Physically Caught or Trapped
- Lost in Building
- Operating in Confined Structural Areas
- Operating under Water or Ice
- Holes, Other
- Unguarded Hole in Structure
- Hole Burned through Roof
- Hole burned in Floor
- Slippery or Uneven surfaces, Other
- Icy surface
- Wet Surface, included are Water/Soap, Foam, etc.
- Loose Material on Surface
- Uneven Surface, included are Holes in ground
- Vehicle or Apparatus, Other
- Vehicle Left the Road or Overturned
- Vehicle Collided with another Vehicle
- Vehicle Collided with Non-vehicular Object
- Vehicle Stopped too fast
- Seat Belt not Fastened
- Firefighter Standing on Apparatus
- Civil Unrest, including Riots/Civil Disturbances
- Hostile
- None
- Undetermined
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I3: OBJECT INVOLVED IN INJURY:
- Object Involved, Other
- Coupling
- Hose not Charged
- Hose, Charged
- Water from Master Stream
- Water from Hose Line
- Water, not from a Line
- Steam
- Extinguishing Agent
- Ladder, Aerial
- Ladder, Ground
- Tools/Equipment
- Knife/Scissors
- Syringe
- FD Vehicle/Apparatus
- FD Vehicle Door, including Apparatus Compartments
- Station Sliding Pole
- Structural Component, Other
- Curb
- Door in Building
- Fire Escape
- Ledge
- Stairs
- Wall, including other Vertical Surfaces
- Window
- Roof
- Floor or Ceiling
- Asbestos
- Dirt, Stones or Debris
- Glass
- Nails
- Splinters
- Embers
- Hot Tar
- Hot Metal
- Biological Agents
- Chemicals
- Fumes
- Poisonous Plants
- Insects
- Radioactive Materials
- Electricity
- Extreme Weather
- Utility Flames, Flares, Torches
- Heat or Flame
- Person, Other
- Person, Victim
- Property and Structures Content
- Animal
- Non-Fire Departmental Vehicle
- Gun, including all other Projectile Weapons
- None
- Undetermined
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J1: WHERE INJURY OCCURRED:
- Location, Other
- Enroute to Fire Department Location
- At Fire Department Location
- Enroute to Incident or Assignment
- Enroute to Medical Facility
- At Scene, in Structure
- At Scene, outside Structure
- At Medical Facility
- Returning from Incident or Assignment
- Returning from Medical Facility
- Undetermined
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J2: STORY WHERE INJURY OCCURRED
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INJURY IN RELATION TO STRUCTURE:
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STORY OF INJURY:
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J3: SPECIFIC LOCATION:
- Specific Location, Other
- Outside at Grade
- On Roof
- On Aerial Ladder or in Basket
- On Ground Ladder
- On Vertical Surface or Ledge
- On Fire Escape or Outside Stairway
- On Steep Grade
- In Open Pit
- In Ditch or Trench
- In Quarry or Mine
- In Ravine
- In Well
- In Water
- In Attic or other Confined Structural Space
- In Structure, excluding Attic, Roof or Wall
- In Tunnel
- in Sewer
- In Motor Vehicle
- In Rail Vehicle
- In Boat, Ship or Barge
- In Aircraft
- Undetermined
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J4: VEHICLE TYPE:
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REMARKS:
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K1: DID PROTECTIVE EQUIPMENT FAIL AND CONTRIBUTE TO THE INJURY?
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ITEM THAT FAILED:
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PROBLEM:
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MANUFACTURER:
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MODEL:
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SERIAL NUMBER:
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CAUSE & EFFECT
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Witness(es):
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INVESTIGATION
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Describe the accident in detail:
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Hospitalized or treated?
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If so, Where?
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Name and Address of Doctor:
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Did the injury result in Off or Light Duty?
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For how long?
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What Acts, Failures to Act, or Conditions -contributes most directly to this event?
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What caused these Acts or Conditions?
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Recommendations for corrective action?
Signed
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Signature of Injured Person:
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Signature of Safety Officer:
