IR Structure Fire v3.0

• Conducted on

  Date
• Location
  Address

Incident

• Incident Address

• Incident Zone

  Zone 1 - City Limits

  Zone 2

  Zone 3

  Shared District - Lenzburg

  Mutual Aid

• Box Alarms Activated

  Select Still Alarm First Alarm Second Alarm Third Alarm Fourth Alarm Fifth Alarm Special Alarm

  • Still Alarm
  • First Alarm
  • Second Alarm
  • Third Alarm
  • Fourth Alarm
  • Fifth Alarm
  • Special Alarm

• Situation Found

• Action Taken

Type And Status

• Property Type

  Select Residential Commercial Industrial Agricultural Mine Recreational Other

  • Residential
  • Commercial
  • Industrial
  • Agricultural
  • Mine
  • Recreational
  • Other

• Business or Building Name?

• Single Family or Multiple Family Dwelling?

• Type of Industry?

• Type of Mine?

• Name of Mine?

• Recreational Type?

• Specify Property Type

• Property use

• Occupant Status

  Select Occupied Unoccupied Vacant

  • Occupied
  • Unoccupied
  • Vacant

• Comments

Property Owner

• Property Owner known?

  Yes

  No

• Property Owner Name

• Property Owner Home Address

• Property Owner Phone Number

• Property Owner Notified of Incident?

  Yes

  No

Alarm/Protection/Suppression/Detection/Utilities/HVAC

• Add Sub-Fields?

  Select Alarm/Protection System Suppression System Utilities Smoke Detectors HVAC

  • Alarm/Protection System
  • Suppression System
  • Utilities
  • Smoke Detectors
  • HVAC

Alarm System

• Alarms

  Yes

  No

• Alarm Type

  Select Smoke Detectors Heat Detectors Pull Stations Water Flow Other

  • Smoke Detectors
  • Heat Detectors
  • Pull Stations
  • Water Flow
  • Other

• Type of alarm

• Alarm Company

  Select ADT Barcom Atlas Pass Tech Electronics Other CSSI Diedold Pinnacle Secure One Self Symplex Yale

  • ADT
  • Barcom
  • Atlas
  • Pass
  • Tech Electronics
  • Other
  • CSSI
  • Diedold
  • Pinnacle
  • Secure One Self
  • Symplex
  • Yale

• Name of Alarm Company

• Alarm Company Contact / Phone Number

Sprinkler/Protection System

• Sprinkler

  Yes

  No

• Did it operate?

  Yes

  No

• FDC Utilized?

  Yes

  No

• Location of FDC

• Comments / Description of System

• Protection System

  Yes

  No

• Type

  Select Sprinkler System Hood System Other

  • Sprinkler System
  • Hood System
  • Other

• Type

Smoke Detectors

• Smoke Detectors Present?

  Yes

  No

• Did Smoke Detectors operate?

  Select Yes No

  • Yes
  • No

• Location of Smoke Detectors

Utilities

Electrical Service

• Type

  Fuse

  Breaker

• Did the device trip or blow?

  Yes

  No

• Service Panel Size and Location

• Comments

• Current Electric Service?

  On

  Off

• Provider

  Select Ameren Egyptian Monroe County

  • Ameren
  • Egyptian
  • Monroe County

• Current Gas Service?

  On

  Off

• Provider

  Ameren

  Other

• Name of Provider

• Current Water Service?

  On

  Off

• Provider

  Village of New Athens

  KWD

  Illinois American

  Other

• Provider

• Current Phone Service?

  On

  Off

• Provider

  AT&T

  Charter

  Other

• Provider

• Other

HVAC System

• Type

• Location

• Comments

Other Heating Equipment

• Type

• Location

• Comments

Exterior Observations

• Observations

• Add media

  Media

Interior Observations

• Observations

• Add media

  Media

Area of Origen

• Comments

• Add media

  Media

Estimated Fire Damage

• Estimated Loss

  Select Minor Damage Moderate Damage Severe/Extensive Damage Total Loss Unknown Damage

  • Minor Damage
  • Moderate Damage
  • Severe/Extensive Damage
  • Total Loss
  • Unknown Damage

• Estimated By

Ignition Source

• Ignition Source Known?

  Yes

  No

• Heat Source

• Material Ignited

• Ignition Factor

• Was equipment involved?

  Yes

  No

• Model and Serial Number

• Photo

  Media

• Were Vehicles Involved?

  Yes

  No

• Vehicle 1 YEAR/MAKE/MODEL

• Vehicle 1 VIN

• Vehicle 1 Photo

  Media

• Add Additional Vehicle?

  Yes

  No

• Vehicle 2 YEAR/MAKE/MODEL

• Vehicle 2 VIN

• Vehicle 2 Photo

  Media

• Add Additional Vehicle?

  Yes

  No

• Vehicle 3 YEAR/MAKE/MODEL

• Vehicle 3 VIN

• Vehicle 3 Photo

  Media

• Add Additional Vehicle?

  Yes

  No

• Vehicle 4 YEAR/MAKE/MODEL

• Vehicle 4 VIN

• Vehicle 4 Photo

  Media

• Comments

Fire spread

• Add Fire Spread Details?

  Yes

  No

• Exposures

  Yes

  No

• Exposure Details

• Materials

• Avenues

• Comments

Smoke Spread

• Add Smoke Spread Details?

  Yes

  No

• Materials

• Avenues

• Comments

Incident Summary

• Incident Commander

  Select 4000 4001 4002 4006 Other NAFD Other FD

  • 4000
  • 4001
  • 4002
  • 4006
  • Other NAFD
  • Other FD

• Other NAFD Incident Commander Name

• Other FD Agency Incident Commander Name

• Sector/Division Chiefs

  Yes

  No

• Select Assignment

  Select Operation Chief Logistics Chief Planning Chief Financial Chief Staging Sector Water Supply Sector Rehab/Medical Sector Rear Sector Front Sector

  • Operation Chief
  • Logistics Chief
  • Planning Chief
  • Financial Chief
  • Staging Sector
  • Water Supply Sector
  • Rehab/Medical Sector
  • Rear Sector
  • Front Sector

• Operation Chief Name

• Logistics Chief Name

• Planning Chief Name

• Financial Chief Name

• Staging Sector Chief Name

• Water Supply Sector Chief Name

• Rehab/Medical Sector Chief Name

• Rear Sector Chief Name

• Front Sector Chief Name

• Fire Departments on Scene

  Select New Athens Fire Lenzburg Fire Freeburg Fire Marissa Fire Hecker Fire St. Libory Fire Fayetteville Fire Smithton Fire Mascoutah Fire East Side Fire Millstadt Fire Red Bud Fire Signal Hill Other Fire

  • New Athens Fire
  • Lenzburg Fire
  • Freeburg Fire
  • Marissa Fire
  • Hecker Fire
  • St. Libory Fire
  • Fayetteville Fire
  • Smithton Fire
  • Mascoutah Fire
  • East Side Fire
  • Millstadt Fire
  • Red Bud Fire
  • Signal Hill
  • Other Fire

• Other FD Name:

• NAFD Apparatus

  Select 4011 4013 4017 4018 4098

  • 4011
  • 4013
  • 4017
  • 4018
  • 4098

• EMS Agencies

  Select New Athens EMS MedStar Ambulance Abbott EMS Other EMS

  • New Athens EMS
  • MedStar Ambulance
  • Abbott EMS
  • Other EMS

• Special Request Agencies

  Select IMT 32 SCCSES Other

  • IMT 32
  • SCCSES
  • Other

• Fire Victims?

  Yes

  No

• Number of Victims

• Number of Victims transported to ER

• Gallons of Water Used

• Hydrant Location(s)

• Tanker Shuttle Deployed?

  Yes

  No

• Address of Fill Site(s)

Remarks

• Building Diagram and Demensions

  Drawing

• Comments

• Add media

  Media

• Report created by

  Sign

• Email this form to nafd62264@gmail.com