Nfirs Module 5 Fire Service Casualty

NFIRS 5.
0 Self-Study Program
Fire Service Casualty

Module: NFIRS-5
Objectives
After completing the Fire Service Casualty Module the student will be
able to:
1. Describe when the Fire Service Casualty Module is to be used.
2. Demonstrate how to complete the Fire Service Casualty Module, given
the scenario of a hypothetical incident.
5-1
Table of Contents
Pretest #5 - Fire Service Casualty Module. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5-3
Using the Fire Service Casualty Module. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5-4
Section A: FDID, Incident Number, Exposure. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5-4
Section B: Injured Person. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5-4
Section C: Casualty Number. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5-5
Section D: Age or Date of Birth. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5-5
Section E: Date and Time of Injury. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5-5
Section F: Responses. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5-5
Section G: Usual Assignment, Physical Condition Just Prior To Injury, Severity,
Taken To, Activity at Time of Injury . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5-6
Section H: Primary Apparent Symptom and Primary Area of Body Injured . . . . . . . . . . . . . . 5-7
Section I: Cause of Firefighter Injury, Factor Contributing to Injury, and
Object Involved in Injury. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5-7
Section J: Where Injury Occurred, Story Where Injury Occurred, Specific Location,
and Vehicle Type. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5-8
Section K: Contribution of Protective Equipment to Injury . . . . . . . . . . . . . . . . . . . . . . . . . . 5-9
SUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5-12
EXAMPLE: Highrise Fire. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5-13
EXERCISE SCENARIO 5-1: Fire Captain Injury on Scene of Fire . . . . . . . . . . . . . . . . . . . . . . 5-16
EXERCISE SCENARIO 5-2: Cary Street Fire. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5-21
NFIRS 5.0 Self-Study Program
Pretest #5 - Fire Service Casualty Module

1. The Fire Service Casualty Module is used to report injuries, deaths, or exposures to fire service,
EMS, and other public safety personnel that occur in conjunction with any incident response.

(a) True.
(b) False.
2. A Basic Module must be completed if the Fire Service Casualty Module is completed.

(a) True.
(b) False.
3. The Fire Service Casualty Module is a required NFIRS Module.

(a) True.
(b) False.
4. The Fire Service Casualty Module should be completed if a firefighter is injured while exercising
at the fire station.

(a) True.
(b) False.
5. The Fire Service Casualty Module should be completed if a firefighter is injured while off-duty
away from the fire station.

(a) True.
(b) False.
5-3
Using the Fire Service Casualty Module
he Fire Service Casualty Module is used to report fire service personnel injuries, deaths, or exposures while on duty. This module is also used to collect information about protective equipment
that failed and contributed to the injury.
An exposure is defined as contact by fire service personnel with a toxic substance or harmful physical
or biological agent through any route of entry (e.g., inhalation, ingestion, skin absorption, or direct
contact). Exposures can be reported regardless of the presence of clinical signs and symptoms.
NOTE: An exposure fire is not the same as an exposure to fire service personnel.
Recording firefighter casualty information provides data on specific, perhaps correctable, hazards. It
also can indicate trends that can lead to future safety improvement efforts. Health and Safety Officers
find this information particularly useful when working to reduce risks at incidents.
Section A: FDID, Incident Number, Exposure

MM
DD
NFIRS5
YYYY
Delete
FDID
State
Incident Date
Station
Incident Number
Exposure
Change
Fire Service
Casualty
Injured Person
Casualty Number
Male
Career
1
1
The
of theNumber
Fire Module is drawn
from Section
A of theCBasic
Module. Use
B information in Section AIdentification
Female
Volunteer
2
2
the data in the Basic Module to help you supply the requested information. If you are using an autoCasualty Number
mated
system the data need
toLastbe
entered only once, then they will beSuffix
transferred automatically
into
First Name
Name
MI
other modules that use the data.
Age or Date of Birth

Age
In years
G1
1
2
3
4
5
6
7
8
0
E
Date of Birth
OR
FDID
Month
Injured Person
Usual Assignment
B
G2
MM
DD
Date and Time of Injury
Date of Injury
YYYY
Midnight is 0000.
State
Day
Month
Day
Responses
Time of Injury
Section B: Injured Person

Incident Date
Year
Station
Year
Incident Number
Hour
Minute
Delete
Number of prior responses
Exposure
during past 24 hours Change
NFIRS5
Fire Service
Casualty
Male
Career
1
Taken To
C Casualty Number
Not transported
Female
Volunteer
2
1
Hospital
0
Other
1
Rested
Suppression
4
Doctors office
Undetermined
U
2
Fatigued
Casualty Number
EMS First Name
5
Morgue/funeral
Last Name
Suffix home
Ill orMIinjured
4
Prevention
Residence
6
Training
Station or quarters
7
Severity
Midnight is 0000.
Responses
Maintenance
Age or DateG
of3Birth
Date and Time
ofOther
Injury
0
D
E
F
1
Report only, including exposure
Communications
2
First aid only
Date of Injury
Administration
Injury
Age
Date of Birth
Activity at TimeTime
of ofInjury
3
Treated by physician (no lost time)
G5
Fire investigation
OR4
Moderate (lost time)
Other
during past 24 hours
In years
Month
Day time) Year
Month
Day
Year
5
Severe
(lost
Hour
Minute
6
Life threatening (lost time)
Activity at time of injury
7
Death
Usual Assignment
Physical Condition Just Prior to Injury
Not transported
G1
G2
G4 Taken To
Identification Number
G
2 4
Section B is used to identify and classify the person injured or exposed using a variety of means.
Start completing Section B by entering an assigned identification number. While the individuals
Social Security Number often is used for this purpose, this is not a recommended practice.
Next, check the appropriate boxes indicating male or female, and the casualtys affiliation (career or
volunteer). Paid-per-call casualties should be considered volunteers when information for this sec1 Object
Hospital
tion isPrimary
entered.
Lastly,
enter the casualtys
firstCause
andoflast
middle initial, and
any
suffix (i.e.,None
Jr.,
Apparent
Symptom
Firefighter
Injury
Involved
0name,
Other
1
1
Suppression
H1
I1 Rested
I34 in Doctors
office
Injury
Undetermined
U
2
Fatigued
Sr., or III) in2 the lines
EMS provided.
5
Morgue/funeral home
3
Prevention
4
Training
5
Primary Part
of Maintenance
Body Injured
6
Communications
7
Administration
Primary injured8body part Fire investigation
0
Other
Ill or injured
Residence
6
Cause of injury
Station or quarters
7
Severity
None
G3 1 I2 Factor Contributing to Injury
Other
0
None
H2
2
First aid only
Object involved in injury
Activity at Time of Injury
3
Treated
by physician (no lost time)
G5
Contributing factor
4
5
Severe (lost time)
Specific Location
Where
6
Where Injury Occurred
Life
threatening (lost time) Vehicle Type Activity at time of injuryComplete ONLY if
J3 Injury Occurred
J4
J1
Specific Location code
7
Death
is >60
1
En route to FD location
1
Suppression vehicle
65
In aircraft
2
2
At FD location
EMS vehicle
64Symptom
In boat, ship, or barge
Complete Cause of Firefighter
Primary
Apparent
Injury
Object Involved
3
Other
FD vehicle
3
En route to incident
scene
Block J4
Primary apparent symptom
5-4
None

MM
DD
YYYY
NFIRS5
Section C: Casualty Number

Delete
Incident Date
Station
Incident Number
Male
Female
1
2
Exposure
Career
Volunteer
1
2
Fire Service
Casualty
Change
Casualty Number
Casualty Number
Last Name
MI
Suffix
MM
DD
YYYY
Each casualty
is given a number.
The
numbers are
assigned
sequentially
starting with one (001), and
Midnight
is 0000.
Responses
Date and Time of Injury A
E
F
Incident Date
continuing based upon how manyFDIDfire serviceState
individuals
were injured orStation
killed atIncident
theNumber
incident, or Exposure
Date of Injury
Time of Injury
resulting from the incident.
ate of Birth
onth
Day
1
2
4
Rested
Fatigued
Ill or injured
Day
0
U
BHour
Year
1
2
A34
5
6
7
Not transported
MI
Hospital
Doctors office
Age or Date ofhome
Birth
Morgue/funeral
Residence
Age
Station
or quarters
Other
OR
In years
Month
Last Name
Cause of injury
Factor Contributing to Injury

Age or Date Iof
2 Birth
OR
In years
Month
Year
Month
Day
Year
Midnight is 0000.
Month
Day
Year
Hour
Minute
Number
during pa
NFIRS5
1
4
5
6
7
0
None
Casualty Number
Suffix
2
First aid only
3
Midnight is 0000.
Responses
4
Moderate (lost
F time)
5
Severe (lost time)
Time of Injury
6
7
Death
Minute
Time of Injury
0
Other
1
Rested
Undetermined
U
2
Fatigued
Casualty
Number
Career
C
Ill or injured
4
Volunteer
Hour
Casua
Casualty
Fire Service
Physical
Condition
Prior to Injury
Exposure
not
both.
If the
ageChange
isJust
entered,
the numbers
are To
Casualty
G
2
G4 Taken

Date of Injury
Day
Year
Delete
1
Suppression
Male
1
2
EMS 1
Female
2
2
3
Prevention
Object Involved
4
Training
I3 in Injury
5
Maintenance
G3
6
Communications
7
Administration
8
Fire investigation
None Date and Time of Injury
0 E Other
Date of Birth
Contributing factor
Specific Location Where

Injury Occurred
Usual Assignment
Day
Suffix
Severity
Section E: Date and Time
of Injury
1
None
Age
Career
Volunteer
1
2
Date of Injury
Date of Birth

G5YYYY
Cause of Firefighter Injury

MI
Male
Female
Last Name
Station
Incident Number
Enter either the casualtys age
dateAssignment
of birth,
but
G1orUsual
assumed to represent years.Activity at time of injury
First Name
1
2
Minute
First Name
1
4
5D
6
7
0
Other
Undetermined

First aid only
MM time)
DD
Treated by physician (no lost
Incident Date
FDID
State
Severe (lost time)
Death
Injured Person
I1
Injured Person
Section
D: Age or Date of Birth
Taken To
G4
Severity
om
ured
Month
G2
G3
Year
Delete
Change
G5
Not
Hospital
Doctors office
Morgue/funeral home
Residence
Station or quarters
Other
Vehicle Type
Complete ONLY if
J4
Primary Apparent Symptom
Object Inv
H
1
I1
I3 in Injury
is >60
1
Physical Condition
Just Prior vehicle
to Injury
Suppression
Not transported
G651 In aircraft
G2
G4 Taken To
2
EMS vehicle
64 DD In boat,
ship, or barge
Complete
1
Cause of injury
Primary
apparent symptom
1
Hospital
3
YYYY
Other
FD
vehicle
e MM
0
Other
NFIRS5
1
Rested
Block J4
In
rail vehicle
Delete
163
Suppression
4
Doctors
4
Non-FD
vehicle
Undetermined
U Primary
2
Fatigued
ty
Noneoffice
Fire
Service
Factor
Contributing
to
Injury
Part
of
Body
Injured
61
In
motor
vehicle
EMS
None
Incident 2
Date
Station
Incident Number
5
Morgue/funeral
H2 Exposure
I2 home
Change
Ill or injured
4
Casualty
In
sewer
354
Prevention
Residence
6
Object involved in injur
In
tunnel
453
Training
Remarks
Station or quarters
7
Severity
49
In structure
Contributing factor
Primary
injured
body
part
5
Maintenance
G
3 Male
Other
0
Career
45
In attic
1
1 only,
1
Report
including exposure
00
Other
C Casualty Number
636
Communications
In
water
Identification
Number
FemaleFirst aid
Volunteer
2
2 only
UU
Undetermined
2
ity 735
Administration
Specific
Location
Where
Activity
at Time
of Injury
In
well
Vehicle Type
Where
Injury
Occurred
C
3
Treated by physician
(no
lost time)
G5 J3 Injury Occurred
J4
834
Fire
investigation
J1
S
In
ravine
4
Casualty Number
Moderate
(lost
time)
is
033
Other
In
quarry or mine
1Suffix En route to FD location
1
Suppression vehicle
Last Name
MI
5
Severe
(lost
time)
32
In ditch or trench
65
In
aircraft
2
2
At FD location
EMS vehicle
6
In open pit
64
Complete
ed 31
3
Other FD vehicle
3
En route to incident scene Activity at time of injury
Block J4
7
Death
28
On steep grade
63
In
rail
vehicle
Midnight is 0000.
Responses
4
Non-FD vehicle
and Time of Injury
4
En route to medical
facility
27
On fire escape/outside
stairs
61
In motor vehicle
E Date
F
5
At scene in structure
26
On vertical surface or ledge
54
In sewer
of Injury
of Injuryfailed and
If protective Time
equipment
of Birth25
On ground
ladderDate
53
In tunnel Object Involved
Primary
Apparent
Symptom
of Firefighter
6 this Cause
At scene
outside Injury
was a factor in
injury,
please
None Remarks
H241 On aerial ladder or in basket
I
1
I3 in Injury
49
In structure
complete the7other side
of this
At medical
facility
23
On roof
45
In
attic
form.
00
Other
h
Day
Year
Month
Day
Year
8
Returning
from
incident
Hour
Minute
22
Outside at grade
36
In water
NFIRS5 Revision 01/01/05
UU
Undetermined
of injury
9 Cause
Returning
from med facility
35
In well
0
Other
None
34
In
ravine
Primary Part of Body Injured
I2U ToUndetermined Not transported 33 NoneIn quarry or mine
G2 H2Physical Condition Just Prior to Injury G4 Taken
J3
Enter the date and time of the injury in Section E. When the injury date is the same as the date of the
incident, enter the same date information that you entered in the arrival block of Section E of the
Basic Module. If the injury date is different, then enter the correct month, day, and year.
The time, both hours and minutes, of the injury is entered using the 24-hour clock, where midnight is 0000.
Section F: Responses
1
2
4
Record the number of incidents that the casualty responded to within the 24-hour period immediObjector
involved
in injury
32
In ditch
trench
ately prior to the time of injury.
1
Hospital
0
Other
Rested
In open pit
Story Where
Injury Occurred 31
Contributing
factor
Primary injured body part
4
Doctors
office
J2
28
On steep grade
Undetermined
U
Fatigued
5
Morgue/funeral home
27
On fire escape/outside stairs
Ill or injured
Check this box and enter the story if the
1 Residence
6
26TypeOn vertical surface or ledge
Specific
Location
Where
injury occurred inside or on a structure Vehicle
Complete ONLY if
J
3
25
On ground ladder Specific Location code
JSeverity
1
Station or quarters J4
7
Injury Occurred
Story of injury
Below grade
is >60
G3 11 En route to FD location
24
On aerial ladder or in
basket
Other
0
1
Suppression vehicle
23
On roof
65
In aircraft
2
2
At
FD
location
EMS
vehicle
2
First aid only
22
Outside at grade
Injury
outside
64
In boat, ship,
2or barge
Activity
atoccurred
Time
of Injury
Complete
3
Other FD vehicle
En
route by
to incident
scene
33
Treated
physician
(no lost time)
Block J4
G5vehicle
63
In rail
4
Non-FD vehicle
En
route to(lost
medical
44
Moderate
time)facility
5-5
61
In motor vehicle
If protective equipment failed and

was a factor in this injury, please
complete the other side of this
form.
NFIR
Injured Person
First Name
NFIRS
5.0 Self-Study Program
1
2
MI
Male
Female
1
2
Last Name
Suffix
Section G: Usual Assignment, Physical Condition Just Prior

OR
To Injury, Severity, Taken To, Activity
at Time of Injury
FDID
State
Injured Person
A
B
FDID
State
First Name
Injured Person
Date of Birth
In years
Month
Date of Injury
Day
Year
Month
Day
Year
Midnight is 0000.
Time of Injury
Hour
DD
G1
YYYY
Usual
Assignment
G2
Describe theAgeofficial assignment of the casualty in Block G1. This may or may not coincide with the
OR
firefighters activity
at the
timeMonth
of injury.
during past
24 hours
Midnight is 0000.
In years
Responses
Day
Year
MonthDate
Day
Year
Hour
Minute
Primary
Apparent
Symptom
Cause of Firefighter
Injury
and Time
of Injury
D Age or Date of Birth
E
F
H1
I1
First Name
Age
Usual Assignment
G1
OR
In years
Minu
Physical Condition Just Prior Delete

to Injury NFIRS5 Taken To
G4
Fire Service
Incident Date
Station
Incident Number
Exposure
Change
1
Hospita
Casualty
0
Other
1
Rested
1
Suppression
4
Doctor
Undetermined
U
2
Fatigued
2
EMS
5
Morgue
Ill or injured
4
MM
DD
YYYY
NFIRS5
Casualty
Number
3
Prevention
Male
Career
1
1
Delete
Residen
6
C
Fire
Service
4
Training
Female
Volunteer
2 Incident
2
Station
7
Severity
Incident Date
Station
Number
Exposure
Change
Casualty0
5
Maintenance
G3 1
Other
Report
only,
including
exposure
6
Communications
Casualty Number
2
First aidSuffix
only
7
Administration
Last Name
MI
Activity at T
Male3
Career
Treated
by physician (no Casualty
1
G5
8
Fire investigation 1
C lost time)Number
4
Moderate
(lost
time)
Identification
Number
Female
Volunteer
2
2
0
Other
0000.
5
Responses
SevereMidnight
(lost istime)
E Date and Time6of Injury
FCasualty Number
7
Death Time
Suffix
Date of Injury
of Injury
Date MI
of BirthLast Name
MM
Age
Career
Volunteer
Date of Birth
G2
Month
1
2
4
Date of Injury
PhysicalPrimary
Condition
Just Prior to Injury
apparent symptom
G4
Day
Part
of Body
Injured Year
0 Month
Other
HRested
2
Undetermined
U
Fatigued
Ill or injured
PhysicalPrimary
Condition
injured body part
Day
Time of Injury
Year
Primary
Taken To
Cause of injury
Not oftransported
Number
prior responses

None
Factor Contributing
to Injury
1 HourHospital
Minute
I2
4
Doctors
office
O
5
Morgue/funeral home
To Contributing factor Not transported
G4 67TakenResidence
Station or quarters
Severity
1
Hospital
0 DeleteOtherNFIRS5
1
Rested
Other
0
2
1
Report
only,
including
exposure
Specific
Location
Where
Vehicle Type
4
Doctors
office
Where Injury
Fire Service
Undetermined
U Occurred
2
Fatigued
J3 Injury 5Occurred
J4
J
1First
2
aid only
Exposure
Morgue/funeral
home
Change
Ill or injured
4
Casualty
3
by physician
(no lost time)
1 Treated
En route
to FD location
1
G5 6
Residence
Suppressio
65
In aircraft
4 Severity
(lost time)
2
2 Moderate
At FD location
Station or quarters
7
EMS vehic
In boat, ship,
or barge
Complete
5
(lost to
time)
3
Casualty
Number64
Other
Other FD v
0
Career
3 Severe
En
route
incident
scene
11
Block
J4
Report
only, C
including
exposure 63
In rail vehicle
6
LifeEn
threatening
(lost time)
4
Non-FD ve
Volunteer
4 First
22
route
to medical
facility
Activity atvehicle
time of injury
61
In
motor
aid
only
7
Death
5 Treated
At scene
in structure
3
by physician
(no lost time)54 GIn5 sewer
53
In tunnel
6 Moderate
At scene
outside
Casualty Number
4
(lost
time)
Remarks
49
In structure
7Suffix
At medical
facility
5
Severe
(lost time)
Cause of Firefighter
Injury
Object Involved
None
45
In
attic
I1 from
00 I3 Other
6
threatening
(lost
time)
8 LifeReturning
incident
in Injury
36
In water
UU
Undetermined
7
Death
Midnight
is 0000.
9
Returning
from
med
facility
Responses 35
In well
E Date and Time of Injury 0 Other
F
Cause of injury
34
In ravine
U of Injury
Undetermined
33
In quarry or mine
Date of Injury
Time
None
Factor
Contributing
to
Injury
Primary Apparent
Part of Body
Injured
Symptom
Object Involved
In ditch or trench
None
None
I12 Number of prior responses 32
I3 in Injury
31
In open pit
Story Where Injury
Occurred
Object
involved
in
injury
JHour2 Minute
28
On steep grade
Month
Day
Year
1
Suppression
2
EMS
3
Prevention
Assignment
G41 Usual
G2
Training
MM
DD
YYYY
5
Maintenance
G3
1
Suppression
6
Communications
2
EMS
Incident Date
Station
Incident
Number
7
Administration
3
Prevention
8
Fire investigation
4
Training
0
Other
5
Maintenance
Male G3
1
6
Communications
Female
2
7
Administration
8
Fire investigation
0
Other
Last Name
MI
H1
None
Record the general physical condition of the casualty just prior to the injury in Block G .
State
son
of Birth
Date of Birth
OR
Month
DescribeHthe
severity or seriousness of the casualty in relation to death and time lost from work in
2
1
Block Year
G3.
Day
27
26
If protective equipment failed
None
Factor Contributing
Primary
Part of
25to Injury
On groundNone
ladder
nment
Physical Condition
Just Prior
to Body
InjuryInjured
was a factor in this injury, ple
2
2
Story of injuryWhere
To Location
Specific
Below
grade
Vehicle
Type or in basket
Not
transported
2
4 3Taken
24
On
aerial ladder
Complete complete
ONLY if
the other side of th
4
1
Specific
Location
Injury
Occurred
23
On roof
form. code
Hospital
1
is >60
0
Other
1
Rested1
En
route
tobody
FDpart
location
22
Outside
at grade
1
ion
Suppression
vehicle
Contributing factor
Primary
injured
Injury occurred
outside
office
4 2 Doctors
Undetermined
U
2
Fatigued
65
In aircraft
2
2
At FD location
EMS vehicle
Morgue/funeral
home
5
Ill or injured
4
64
In
boat,
ship,
or
barge
Complete
3
n
Other FD vehicle
3
En route to incident scene
Location Where Block J4
636 Specific
InResidence
rail vehicle
Type vehicle
Complete ONLY if
4Vehicle
Non-FD
3
4 1 En route to medical facility
or
quarters
4
Severity
617 Injury
InStation
motor
vehicle
Occurred
nce
3
is >60
5
At
scene
in
structure
Other
0
54
In sewer
route toexposure
FD location
1
Suppression vehicle
1
Report1only,En
including
cations
53
tunnel
6
At
scene
outside
65
In
aircraft
2
2
At
FD
location
EMS
vehicle
Remarks
2
First aid only
ation
49 Activity
structure
atship,
Timeorofbarge
Injury Complete
64
In boat,
7 by physician
At medical
facility
3
Other FD vehicle
3
3
En
route to
incident
scene
Treated
(no
lost time)
5 63
Block J4
tigation
45
atticvehicle 00
In
rail
Other
4
8 (lost
Returning
incident
4
Non-FD vehicle
4
Moderate
time) tofrom
4
En
route
medical
facility
36
water vehicleUU
61
In motor
Undetermined
9(lostAt
Returning
med facility
5
Severe5
time)
35
well
scene infrom
structure
54
In sewer
0
Other
6
Life threatening
(lost outside
time)
34
ravine
53
tunnel
6
At
scene
Activity atIn
time
of injury
Remarks
Undetermined
33
quarry or mine
7
Death 7U
49
In structure
At medical facility
32
ditch or trench
45
In attic
00
Other
8
Returning from incident
31
open pit
In water
Story Where Injury Occurred 36
UU
Undetermined
9 2 Returning
med facility
28
Onwell
steep gradeObject Involved
In
parent Symptom
Cause from
of Firefighter
Injury 35
None
0
1Other
3 in Injurystairs
27
Onravine
fire escape/outside
34
In
this box and enter the story if the
1U Check
26
On
vertical
surface
or
ledge
Undetermined
33
In
quarry
or
mine
injury occurred inside or on a structure
25
Onditch
ground
ladder
32
In
or trench
Cause
injury
ymptom
Story ofofinjury
Below grade
24
Onopen
aerialpitladder or in basket
31
In
Story Where Injury Occurred
23
On
roof
form.
None
2
28
steep grade
t of Body Injured
None at grade
2
22
Outside
27
Injury occurred outside
2
1
26
On vertical
surface
ledge
Object
involvedor
in injury
25
On ground ladder
Contributing
factor Below grade
y part
Story of injury
24
On aerial ladder or in basket
23
On roof
form.
22
Outside
Injury occurred
outside
Specific Location
Where
Vehicle
Type at grade
2
Occurred
Primary apparent
injured body
part
Primary
symptom
H
J
GJ
Contributing
factor
Cause of injury
G casualty went after the injury.

Use Block G to record where the
5-6
J3
Injury Occurred
J4
Complete ONLY if
nment
1
2
4
on
ce
ations
tion
igation
G2
G3
arent Symptom
mptom
of Body Injured
Rested
Fatigued
Ill or injured
0
U
Other
Undetermined
Severity
1
2
3
4
5
6
7

First aid only
Severe (lost time)
Death
G4
A
Taken To
NotMM
transported
DD
YYYY
1
Hospital
Incident Date
4FDID Doctors office
State
5
Morgue/funeral home
Residence
6 NFIRS
5.0 Self-Study Program
Station
7
Injured
Personor quarters
Other
0
GName
5
AFirst
Activity at Time of Injury MM
FDID
DD
Age
Male
Female
1
2
Exposure
Career
Volunteer
1
2
Suffix
Exposure
Incident Number
Date of BirthIdentification Number
Career
Time of Injury
Volunteer
Use Block G5 to
describe
whatInjury
type of activityORwas
taking
place atNone
the time the injury occurred.
Cause
of Firefighter
Object
Involved
I1
I3 in Injury
In years
Month
Day
Year
Month
Day
Year
Hour
Minute
First Name
Last Name
MI
You will need to enter a code as
part of the description.
Use
the NFIRS Complete Reference Guide (CRG)Suffix
of injury
to identify theCause
activity
of the firefighter
at the time of the injury.
Usual Assignment
Midnight is 0000.
None
To
Factor Contributing to
Injury
G
1 Age or Date
G2 Physical Condition E
G4 Taken
None of Birth
D
I2
Rested
Fatigued
Ill or injured
Ca
0 Date ofOther
Injury
Undetermined
U
Cha
Midnight is 0000.

Male
1
1
Date of Injury2
Female
2
in injury 1
Age SuppressionObject involvedDate
of Birth
Cha
Casu
Dele
Station

Age
or Date of Birth
Injured Person
D
B
Incident Number
YYYY
Last Name
MI
Incident Date
State
Dele
Station
1
4
5
6
7
0
FCas
Num
durin
Casu
Hospital
Time of Injury
Doctors office
Morgue/funeral Num
ho
durin
HourResidence
Minute
Station or quarters
Other
1
2
2
EMS
OR
4
3 In years
Prevention
Month
Day
Year
Month
Day
Year
4
Training
Severity
Vehicle Type
Occurred
Complete ONLY if
J3 Injury Occurred
5
Maintenance
G
3
J4
1
is >60 Physical
6
Communications
Assignmentvehicle
Condition Just Prior to Injury
D location
1 Usual
Suppression
To
2
First aid only
G
1
G
2
G4 Taken
7
Administration
Activity at Time of InjuN
65
In
aircraft
2
n
EMS vehicle
3
Treated
by physician (no lost time)
G
5
8
Fire
investigation
1
Hospital
64
Complete
Rested
3 Suppression
Other FD vehicle
cident scene
41
Moderate (lost 0time) Other
1
Block J4
0
Other
63
In rail vehicle
4
Doctors office
Undetermined
U
Fatigued
Non-FD vehicle
52
edical facility
Severe (lost time)
1
2 4 EMS
61
In motor vehicle
5
Morgue/funeral ho
Ill
orthreatening
injured
4
6
Life
(lost
time)
ructure
3
Prevention
54
In sewer
Activity
of injury
Residence
6 at time
7
Death
53
In tunnel
4
Training
ide
Station or quarters
7
Remarks
Severity
49
In structure
5
Maintenance
G3 1
cility
Other
0
45
In attic
6
Communications
00
Other
m incident
36
In water
2
First
aid
only
Primary
Apparent
Symptom
Cause
of
Firefighter
Injury
Object
UU
Undetermined
Activity at Time
Injur
m med facility
H781 Administration
I3 inofInjur
35
In well
3
Treated byI1physician (no lost
time)
MM
DD
YYYY
G
5
NFIRS5
Fire investigation
Delete
A 34 In ravine
4
Moderate
(lost
time)
0
Other
Fire Service
d
33FDID In quarry or State
mine
Incident Date
Incident Number
Exposure (lost time)
5
Severe
Cause
of injury
PrimaryStation
apparent symptom
Change
Casualty
32
In ditch or trench
6
None
In open pit
Primary Part of Body Injured 7
njury Occurred 31
None
Death
H2
I2
28
On steep grade
Injured
Casualty Number
Male
Career
1
1
27
OnPerson
fire escape/outside stairs
Object involved in
C
er the story if the B
26
On vertical surface or ledgeIdentification Number
Volunteer
2 part Female
2
r on a structure
Contributing factor
Primary
injured
body
If protective
equipment
failed
and
Object
25
On ground ladder
was
H1a factor in this injury, please
I1
I3 in Injur
Below grade
24
Casualty Number
23
On roof
form.
Specific
Location Where
First Name
Last Name
Vehicle Type
MI
Suffix
J3 Injury
22
Outside at grade
J4
J1 Primary apparent symptom
NFIRS5 Revision
01/01/05
Occurred Cause of injury
1
En
route Part
to FDoflocation
1
Suppression vehicle
None
Primary
Body Injured
FactorResponses
Contributing to Injury
Midnight is 0000.
None
In aircraft I2
H
Date and Time of Injury65
2
2 2 At FD
EMS vehicle
D Age or Date of Birth
E location
F
64
Complete
Object involved in
3
Other
FD vehicle
3
Block J4
63 TimeInofrail
vehicle
Date of Injury
Injury
Age
Date of Birth
4
Non-FD vehicle
4
En
route
tobody
medical
facility
Primary
injured
part
61
In motor vehicle Contributing factor
5
54
In sewer
OR
In years
53 HourIn tunnel
Month
Day
Year 6
Month outside
Day
Year
At scene
Minute
Remarks
Specific
Location
Where
Vehicle Type
In structure
2
J493 Injury
7
J4
J1 At medical facility
Occurred
45
In attic
00
Other
8
Returning
incident
1
En
routePrior
tofrom
FD
1
Suppression vehicle
36
In water
Just
tolocation
Injury
UU
Undetermined
In
aircraft
9
Returning
from med facility
Not transported
G1 Usual Assignment
G2 Physical Condition
G4 65
2
2
At
FD location
EMS vehicle
35Taken
InTo
well
64
In
boat,
Complete
0
Other
34
In
ravineship, or barge
3
Other FD vehicle
En
to incident scene
1
Hospital
Block J4
0routeOther
1
Rested 3U
63
In
rail
vehicle
Undetermined
33
In
quarry oroffice
mine
1
Suppression
4
Non-FD vehicle
4
4
Doctors
En
to medical facility
UrouteUndetermined
2
Fatigued
61
In
motor
vehicle
32
In ditch or trench
2
EMS
5
Morgue/funeral
home
5
54
In
sewer
Ill or injured
4
31
In open pit
3
Prevention
Where
Injury Occurred 53
Residence
6
In
6J2 Story
At scene
outside
28
Ontunnel
steep grade
Remarks
4
Training
49
In
structure
Station
or quarters stairs
7
Severity
7
At medical facility
27
On
fire escape/outside
5
Maintenance
Check
this
box
and
enter
the
story
if
the
G3 1
45
In
attic
Other
0
1
26
On vertical surface
00 or ledge
Other
Returning
from
occurred inside
or onincident
a structure
Report 8only,injury
including
exposure
6
Communications
36
In
25
Onwater
ground ladder
UU
Undetermined
from med
facility
2
First aid9 onlyReturning
Story of injury
35
In
well
Below grade
7
Administration
at Time
of or
Injury
24 Activity
On aerial
ladder
in basket
3
Other
Treated0by physician
(no lost time)
In
G5 34
8
Fire investigation
23
Onravine
roof
form.
4
Moderate
time)
U (lost
Undetermined
33
In
quarryatorgrade
mine
0
Other
22
Outside
Injury
occurred
outside
2
32
In
ditch
or
trench
5
Severe (lost time)
31
In open pit
6
Life threatening
time)
Story(lost
Where
Injury Occurred Activity
at time of injury
28
On steep grade
7
Death J2
Contributing factor
part
Section H: Primary Apparent Symptom and

Primary Area of Body Injured
Record the primary symptom and areas of injury in Section H. Use Block H to enter the code that
describes the casualtys most serious injury.
The Emergency Medical Technician (EMT) or the person responsible for the prehospital emergency
care phase of treatment may provide you with a determination of what appears to be the casualtys
most serious injury.
Block H is used to record the body part or area that sustained the most serious injury. It should be
the part of the body affected by the primary apparent symptom.
Section I: Cause of Firefighter Injury,

Factor Contributing to Injury, and Object Involved in Injury
In Section I, record the data that describes the factors that caused the injury. Use the CRG to complete
this section.
1
H1
I
2
H2
27
26
Cause
of Firefighter
Injury 25
Story of injury
Below grade
24
1
23
22

On ground ladder
Object Involved
On aerial 3ladder or in basket
in Injury
On roof
Outside at grade
Nonewas a factor in this injury, please
Cause of injury
None

None
I2
Use Block I1 to describe the situation or circumstance that directly resulted
in the casualty.
Contributing factor
J1
1
2
3
At FD location
J3

Injury Occurred
65
64
In aircraft
5-7J4
Complete
Block J4
Vehicle Type
1
2
3
Suppression vehicle
EMS vehicle
Other FD vehicle
Complete ONLY if
is >60

form.
Month
G2
Day
Year
Month
Day
6Year
7

H1Rested
0
Other
1
Undetermined
U
2
Fatigued
Primary
apparent symptom
Ill or
injured
4
Life threatening
(lost time)during past 24 hours
Hour
Minute
Death
Injured Person
A
Taken To B
Not transported
FDID
State
Cause of
Firefighter
Injury
IHospital
1
1
4
Doctors office
First Name
5
Morgue/funeral
home
Cause of injury
Injured
Person
B
Residence
6
None
Factor
Contributing
to Injury
or quarters
7
IStation
2
Age
or
Date
of
Birth
Other
0
D
G4
MM
DD
YYYY
Number
Incident Identification
Date
Object
I3
Station
Involved
in Injury
Female
Incident
Number
Male
1
2
Career
Volunteer
Exposure
1
2
Male
Female
1
2
Career
Volunteer
None
Last Name
MI
1
2
Suffix
None
Severity
Midnight is 0000.
H2
E Date and Time of Injury
1
First Name
Last Name
MI
Suffixof Injury
Date of Injury
Time
2
First
aidinjured
onlybody part
Age
Date of Birth
Contributing
factor
Primary
Activity at
Time of
Injury
3
G5
OR
4
Midnight is 0000.
In
yearsor Date of Birth
MonthType Day
Year
Age
Date Day
and TimeYear
of Injury
Hour
Minute
Vehicle
Where(lost
Injury
Occurred
5
Complete
ONLY if
Severe
time)
D
EMonth
J
3
J
4
J
1
Injury
Occurred
6
is
>60
Date of Injury
Time of Injury
Age
of Birth
En route to FD2 location
1 Date
Suppression
vehicle
7 1 Death
Usual Assignment 2
65
In aircraft
2
At FD location
EMS
vehicle
Taken
To
G1 Complete
G2
G4
OR
64
3 Month
Other FD
3
In years
Day vehicle
Year
Month
Day
Year
Block J4
Hour Hospital
Minute
1
63
In rail vehicle
0
Other
1 vehicle
Rested
mptom
Cause facility
of Firefighter
Object
Involved 4 NoneNon-FD
4
En route to medical
1
Suppression
61 Injury
In motor vehicle
4
Doctors o
I
1
I
3 in Injury
Undetermined
U
2
Fatigued
5
2
EMS
54
In sewer
5
Morgue/fu
Ill or Condition
injured Just Prior to Injury
4 Physical
Usual
Assignment
3
Prevention
53
In tunnel
6
At scene outside
6TakenResidenc
To
Remarks G2
G
1
G
4
Cause of injury
49
In structure
4
Training
7
At medical facility
Station or
7
Severity
1
Hospital
45
In attic
Maintenance
0
Other
Rested
G3 11
00 5 Other
None
Other
8
0
Returning from
incident
Factor
njured
Suppression
Report only, including
exposure
4
Doctors o
I2 from med facility 36 In water NoneUU 126 Undetermined
Communications
Undetermined
U
2
Fatigued
9
Returning
EMS
35
In well
2
First
aid
only
5
Morgue/fu
7Object involved
Administration
Ill or injured
4
in injury
Activity at Tim
0
Other
3
Prevention
34
In ravine
3
Residence
G5 6
8
Fire investigation
U
UndeterminedContributing factor
33
In quarry or mine 4
Training
4
Station or
7
Severity
0
Other
32
In ditch or trench 5
Maintenance
G3 15
Severe (lost time)
Other
0
31
In
open
pit
Report
only,
including
exposure
3
6
Communications
StoryLocation
Where Injury
Occurred
6
Specific
Where
Vehicle
Type
J
2
28
On
steep
grade
Complete
ONLY
if
2
First
aid
only
J3 Injury Occurred
7
Administration
J4 On fire escape/outside
7
Death
Activity at Tim
27
stairs
3
G5
is >60
8
Fire investigation
1
1
26
On
vertical
surface
or
ledge
Suppression
vehicle
4
0
Other
65
In aircraft
25
On2 ground
ladder
EMS
vehicle
5 please
Severe (lost time)
was a factor in this injury,
of injury
64
In boat,Story
ship,
or bargeBelow grade
Primary
Apparent
Symptom
Complete
24
On
aerial
ladder
or
in
basket
3
Other FDH
vehicle
complete the other side
ene
6 of thisLife threatening
1
I1 (lost time)
I3
Block J4
63
In rail vehicle
23
On4 roof Non-FD vehicle
form.
ility
7
Death
61
InInjury
motor
vehicle
22
Outside
at
grade
occurred outside
2
G3
t
cility
urred
de
Enter the code and description for the most significant factor contributing to the casualtys injury in
Block I .
Then enter the code and description of the object that contributed to the injury in Block I .
54
53
49
45
36
35
34
33
32
31
28
27
26
25
24
23
22
Section J: Where Injury Occurred, Story Where Injury

Occurred, Specific Location, and Vehicle Type
In sewer
In tunnel
In structure
In attic
00
Other
In water
UU
Undetermined
In well
In ravine
In quarry or mine
In ditch or trench
In open pit
On steep grade
On ground ladder
On roof
Outside at grade
Cause of injury
Remarks
H
H12
None
Primary
Symptom
Primary Apparent
Part of Body
Injured
II12
Cause
Firefighter Injury
Factor of
Contributing
to Injury
Section J is completed to describe the location where the injury occurred.

En
route
FDpartlocation
1
Primary
injuredto
body
At FD location
2
If protective equipment failed
3 andEn route to incident scene
was a factor in this injury, pleaseWhere Injury Occurred
4this
1 En route to medical facility
complete the other side ofJ
form.
At scene
in FD
structure
15
En
route to
location
NFIRS5
Revision 01/01/05
At FD
scene
outside
26
At
location
At medical
37
En
route to facility
incident scene
Returning
incident
48
En
route tofrom
medical
facility
Returning
med facility
59
At
scene infrom
structure
Other
60
At
scene outside
Undetermined
7U
At
medical facility
8
9J2
0
1
U

Story
Where
Injury
Occurred
Returning
from
med
facility
Other
Undetermined
injury
occurred inside or on a structure
J2
J3
65
64
63
3
61
54
65
53
64
49
63
45
61
36
54
35
53
34
49
33
45
32
36
31
35
28
34
27
33
26
32
25
31
24
28
23
27
22
26
25
24
23
22
Mark the boxes in Block J1 to indicate where the injury occurred.

Story of injury
2
1

Story of injury
Below grade
Below grade
Obj
None
None
I2 Where
Specific Location
Vehicle Type
J
4
Obje
Injury Occurred
Contributing factor
1
Suppression
In aircraft
2
EMS vehicle
Complete
3
Other FD veh
Specific
Location Where Block J4
Vehicle Type
In rail vehicle
Non-FD vehi
J4 4
Injury Occurred
In motor vehicle
In sewer
In
In aircraft
tunnel
In
ship, or barge
In boat,
structure
Complete
Block J4
In
In rail
atticvehicle 00
Other
In
In motor
water vehicleUU
Undetermined
In
In sewer
well
In
In tunnel
ravine
In
In structure
quarry or mine
In
In attic
ditch or trench
00
Other
In
In water
open pit
UU
Undetermined
In
Onwell
steep grade
In
Onravine
fire escape/outside stairs
In
or surface
mine or ledge
Onquarry
vertical
In
or trench
Onditch
ground
ladder
In
pitladder or in basket
Onopen
aerial
On
On steep
roof grade
On
fire escape/outside
stairs
Outside
at grade
On ground ladder
On roof
Outside at grade
1
2
Remarks
3
4
5-8
Suppression
EMS vehicle
Other FD veh
Non-FD vehic
Remarks
If protective equipment failed an

was a factor in this injury, pleas
form.
If protective equipment failed an

form.
For Block J2, check Box 1 if the person was inside or on the structure, and enter the story where the
injury occurred on the line provided.
Check Box 2 if the injury occurred outside.
I3
Cause
of injury
Contributing
factor
Primary
symptom
Primaryapparent
injured body
part
H2
J1
None
rson
Last Name
MI
H2
1
2
Male
Female
Career
Volunteer
1
2
OR
gnment
sion
on
nce
ications
ration
stigation
J3
Where Date
Injury
Occurred
of Injury
Month
Day
Year
At FD location
3
4
En route to medical facility
G2 Physical 5Condition
6
At scene outside
0
Other
1
Rested
7
At medical
facility
Undetermined
U
2
Fatigued
Ill or 8injured
4
9
Returning from med facility
Other
Severity 0
G3 1
U only,
Undetermined
Report
including exposure
parent Symptom
2
3
4
5
6
7
First aid only

Where(no
Injury
Treated
physician
lostOccurred
time)
J2 byStory
Checktime)
this box and enter the story if the
Severe
1 (lost
Story of injury
Below grade
Death
2
rt of Body Injured
Responses
Specific
Location Where
Time of Injury
Injury Occurred
Vehicle Type
J4
Suppression vehicle

65
In
aircraft
Hour
Minute
2
EMS vehicle
64
Complete
3
Other FD vehicle
Block
J4
63
In rail vehicle
4
Non-FD vehicle
61
In motor vehicle
To
Not transported
4 Taken
54
In sewer
53 1 In tunnel
Hospital
Remarks
49 4 In structure
Doctors office
45
In attic
00 home
Other
5
Morgue/funeral
36
In water
Undetermined
Residence UU
35 6 In well
Station or quarters
34 7 In ravine
Otheror mine
33 0 In quarry
32
In ditch or trench
31
In open at
pit Time of Injury
Activity
5
28
On steep grade
27
26
25ActivityOn
ground
at time
of injury ladder
24
23
On roof
form.
22
Outside at grade
Complete ONLY if
is >60
Object Involved
in Injury
I1
I3
Block J3 is used to identify the casualtys specific location at the time of the injury.
None
Cause of injury
symptom
Note None
the codes Factor
by theContributing
specific location
If you selected a vehicle code greater than 60,
to Injury descriptions.
None
I2
also select the vehicle type in J4.
Contributing factor
ody part
y Occurred
FD location
on
incident scene
medical facility
structure
tside
facility
rom incident
rom med facility
ed
Injury Occurred
enter the story if the

e or on a structure
de
Midnight is 0000.
Year
2
Day
None
Contributing factor
Month
Casualty Number
I2
Suffix
e of Birth
J1
Casualty Number
Cause of injury
None
Date of Birth
Below grade
J3
65
64
63
61
54
53
49
45
36
35
34
33
32
31
28
27
26
25
24
23
22

Injury Occurred
J4
In aircraft
Complete
Block J4
In rail vehicle
In motor vehicle
In sewer
In tunnel
In structure
4
In attic
00
Other
In water
UU
Undetermined
In well
In ravine
In quarry or mine
In ditch or trench
In open pit
On steep grade
On ground ladder
On roof
Outside at grade
Vehicle Type
1
2
3
4
Complete ONLY if
is >60
Suppression vehicle
EMS vehicle
Other FD vehicle
Non-FD vehicle
Block J is used to identify the Remarks

vehicle type that was involved.
Section K: Protective Equipment
Section K allows you to record Ifdata

involving
protective
equipment. If protective equipment failed
protective
equipment failed
and
complete
the other
side ofbox
this in Block K1. Complete the rest of Section K if you
and contributed to the injury, mark
the
Yes
form.
have marked the Yes box.
K1
Did protective equipment fail and contribute to the injury?
Yes
Please complete the remainder of this form ONLY if you answer YES.
No
Equipment
Sequence
Number
NFIRS5
Fire Service
Casualty
Protective Equipment Item

Protective Equipment Problem
NOTE:
K2 Equipment Sequence Number - When more than one piece of protective equipment
K3 was a factor in the casualtys injury,
Check
one box toconsecutively
indicate the mainstarting
problem that occurred.
a module should be completed for each piece of equipment. Each item is given a number that is assigned
Head or Face Protection
Coat, Shirt, or Trousers
with one (001) and continuing based on how many protective equipment items were 11
involved.Burned
11
12
13
14
15
16
17
10
Helmet
Full face protector
Partial face protector
Goggles/eye protection
Hood
Ear protector
Neck protector
Other
21
22
23
24
25
26
27
28
20
Protective coat
Protective trousers
Uniform shirt
Uniform T-shirt
Uniform trousers
Uniform coat or jacket
Coveralls
Apron or gown
Other
5-9
Boots or Shoes
31
Knee length boots with steel baseplate and steel toes
12
Melted
21
Fractured, cracked or broken
22
Punctured
23
Scratched
24
Knocked off
25
Cut or ripped
K1
K2
Yes
No
K3
11
12
13
14
15
16
17
10
21
22
23
24
25
26
27
28
20
NFIRS5
Equipment
Sequence
Number
Fire Service
Casualty

Check one box to indicate the main problem that occurred.
11
Burned
12
Melted
21
22
Punctured
23
Scratched
24
Knocked off
25
Cut or ripped
31
Trapped steam or hazardous gas
32
Insufficient insulation
33
Object fell in or onto equipment item
41
Failed under impact
42
Face piece or hose detached
43
Exhalation valve inoperative or damaged
44
Harness detached or separated
45
Regulator failed to operate
46
Regulator damaged by contact
47
Problem with admissions valve
48
Alarm failed to operate
49
Alarm damaged by contact
51
Supply cylinder or valve failed to operate
52
Supply cylinder/valve damaged by contact
Special Equipment
53
Supply cylinderinsufficient air/oxygen
61
62
63
64
65
66
67
68
69
71
72
73
74
75
76
77
78
79
70
00
94
Did not fit properly
95
Not properly serviced or stored prior to use
96
Not used for designed purpose
97
Not used as recommended by manufacturer
00
Other equipment problem
Helmet
Full face protector
Hood
Ear protector
Neck protector
Other
Protective coat
Protective trousers
Uniform shirt
Uniform T-shirt
Uniform trousers
Coveralls
Apron or gown
Other
Boots or Shoes
31
32
33
34
35
36
37
38
30

Knee length boots with steel toes only
3/4 length boots with steel baseplate and steel toes
3/4 length boots with steel toes only
Boots without steel baseplate and steel toes
Safety shoes with steel baseplate and steel toes
Safety shoes with steel toes only
Non-safety shoes
Other
Respiratory Protection
41
42
43
44
45
46
40
SCBA (demand) open circuit

SCBA (positive pressure) open circuit
SCBA closed circuit
Not self-contained
Cartridge respirator
Dust or particle mask
Other
Hand Protection
51
52
53
54
55
50
Firefighter gloves with wristlets

Firefighter gloves without wristlets
Work gloves
HazMat gloves
Medical gloves
Other
Proximity suit for entry

Proximity suit for non-entry
Totally encapsulated, reusable chemical suit
Totally encapsulated, disposable chemical suit
Partially encapsulated, reusable chemical suit
Partially encapsulated, disposable chemical suit
Flash protection suit
Flight or jump suit
Brush suit
Exposure suit
Self-contained underwater breathing apparatus (SCUBA)
Life preserver
Life belt or ladder belt
Was the failure of more
Personal alert safety system (PASS)
than one item of protective
Radio distress device
equipment a factor in the
Personal lighting
injury? If so, complete an
Fire shelter or tent
additional page of this
Vehicle safety belt
form for each piece of
failed equipment.
Special equipment, other
Protective equipment, other
UU
K4
Undetermined
Equipment Manufacturer, Model and Serial
Number
Manufacturer
Model
Serial Number
Block K2 is used to record the protective equipment item that failed and was a factor in the casualtys
injury.
The choices are grouped into the following categories:
Hand Protection
Special Equipment

Boots or Shoes
5-10
NFIRS5
Revision 05/01/03
nt fail and contribute to the injury?
Yes
r of this form ONLY if you answer YES.
No
tem
or
tion
K3
Protective coat
Protective trousers
Uniform shirt
Uniform T-shirt
Uniform trousers
Coveralls
Apron or gown
Other
21
22
23
24
25
26
27
28
20
with steel baseplate and steel toes

with steel toes only
h steel baseplate and steel toes
h steel toes only
baseplate and steel toes
teel baseplate and steel toes
teel toes only
NFIRS5
Equipment
Sequence
NFIRS
5.0 Self-Study Program Fire Service
Number
Casualty

11
Burned
12
Melted
21
22
Punctured
23
Scratched
24
Knocked off
25
Cut or ripped
31
32
33
41
Failed under impact
42
43
en circuit
ssure) open circuit
t
44
45
r
sk
46
47
48
49
51
52
53
94
95
96
97
00
UU
Undetermined
with wristlets
without wristlets
ntry
on-entry
ed, reusable chemical suit
ed, disposable chemical suit
ted, reusable chemical suit
ted, disposable chemical suit
uit
erwater breathing apparatus (SCUBA)
belt
y system (PASS)
3 toitem
Use
record
the most
thanKone
of protective
ce
other
ent, other
uted
to the injury.
failed equipment.
K4

Number
significant Manufacturer
problem with the piece of equipment that failed and contribModel
Serial Number
5-11
NFIRS5
Revision 05/01/03
uit for non-entry

apsulated, reusable chemical suit
apsulated, disposable chemical suit
capsulated, reusable chemical suit
capsulated, disposable chemical suit
ction suit
mp suit
uit
ed underwater breathing apparatus (SCUBA)
er
ladder belt
ert safety system (PASS)
ess device
hting
or tent
ety belt
failed equipment.
ipment, other
quipment, other
95
96
97
00
UU
Undetermined
K4

Number
Manufacturer
Model
Serial Number
NFIRS5
Revision 05/01/03
Block K4 provides space to record information about the equipment manufacturer, model number
or type, and the serial number.
Enter the name of the company that made/manufactured the piece of equipment involved on the
first line. Enter the manufacturers model name in the next space. If a model name is not available,
you should give a general physical description of the equipment. Enter the manufacturers serial
number, usually stamped on the equipments identification plate on the last line.
SUMMARY
The Fire Service Casualty Module is used to report fire service personnel injuries, deaths, or exposures while on duty. This casualty information is used by Health and Safety Officers to reduce the
risks associated with all types of work-related casualties. The Fire Service Casualty Module is also
used to collect information about protective equipment that failed and contributed to the injury.
Researchers, educators, equipment makers, design engineers, and governmental regulatory agencies may use the specific information provided to make various determinations, such as which
specific pieces of equipment are involved in casualties. Complete information must be collected
for each individual casualty in order to provide the data needed to make determinations related
to improving job safety.
5-12
EXAMPLE: Highrise Fire

Directions: Read the call information in the example below.Then look at the completed Fire Service Casualty Module form. Look
at each section and follow along with the proper use of the information as applicable to the Fire Service Casualty Module.
On May 21, 1999, FDID #TR300 received a Highrise Box 13-28 at 2235 hours and responded to
2045 Beach Blvd., North Brook, Wisconsin 12345. Fire was reported to be located on the 12th
floor. The crew assigned to Engine 131 was sleeping prior to the call. It was their first call during
a 24-hour shift that began at 0700 hours. E-131 responded with a crew of four personnel from
Station #1. They assigned incident #7865481 to the response.
Ambulance 139 was returning to the station from a previous call and was sent on the box assignment. The ambulance arrived first. Their initial onscene report was of fire showing from the 12th
floor with people trapped. They requested a second alarm. Chief 13 advised E-131 to do search
and rescue and assigned the second engine company to attack the fire and provide a safe exit for
evacuation. The personnel on E-131 consisted of career personnel Captain Tom Jones, Tech. Marc
Helton, F/F Bob Wilson, and F/F Kenny Segal. F/F Wilson was 57 years old and the most experienced in suppression. He led the crew to the stairwell and planned to walk up to the 12th floor.
The building was about 20 years old and did not have an elevator emergency control system. At
2245, as the crew approached the 10th floor F/F Wilson began complaining of chest pains and
shortness of breath, Captain Jones advised the officer in charge that his crew was taking a couple
minutes break to rest. At this point F/F Wilson collapsed and stopped breathing. Captain Jones
started CPR on F/F Wilson and advised officer in charge to call for a medic unit for F/F Wilson.
CPR was continued until the arrival of the advanced life support unit. F/F Wilson was removed
from the building and then transported to Mercy General Hospital where he was pronounced
dead at 2350 hours.
5-13
5-14
K1
K2
Yes
No
K3
11
12
13
14
15
16
17
10
21
22
23
24
25
26
27
28
20
NFIRS5
Equipment
Sequence
Number
Fire Service
Casualty

11
Burned
12
Melted
21
22
Punctured
23
Scratched
24
Knocked off
25
Cut or ripped
31
32
33
41
Failed under impact
42
43
44
45
46
47
48
49
51
52
Special Equipment
53
61
62
63
64
65
66
67
68
69
71
72
73
74
75
76
77
78
79
70
00
94
95
96
97
00
UU
Undetermined
Helmet
Full face protector
Hood
Ear protector
Neck protector
Other
Protective coat
Protective trousers
Uniform shirt
Uniform T-shirt
Uniform trousers
Coveralls
Apron or gown
Other
Boots or Shoes
31
32
33
34
35
36
37
38
30

Non-safety shoes
Other
41
42
43
44
45
46
40

SCBA closed circuit
Not self-contained
Other
Hand Protection
51
52
53
54
55
50

Work gloves
HazMat gloves
Medical gloves
Other

Flight or jump suit
Brush suit
Exposure suit
Life preserver
Personal lighting
Vehicle safety belt
failed equipment.
5-15
K4

Number
Manufacturer
Model
Serial Number
NFIRS5
Revision 05/01/03
EXERCISE SCENARIO 5-1:

Fire Captain Injury on Scene of Fire
Directions: Read the call information in the exercise below. Use the information provided to complete the Fire Service Casualty
Module form. Compare your work to the answers provided on the completed Fire Service Casualty Module form. If your answers
are different from the ones provided, read over the Fire Service Casualty Module again.
At 0655 on November 21, 1997, the A-1 Alarm Company notified the Regional 9-1-1 dispatch
center of smoke detector activation at the Busy Bee Market located at the corner of First and Main
Streets in the town of North Brook, WI 12345. Engine 45 and Truck 22 from Station 13 of the
North Brook Fire Department (FDID #TR100) were dispatched to the incident at 0658.
Truck 22 arrived at the market at 0705 and reported smoke showing from the one-story building
and water running from under the front door. The crew of the truck company forced entry and
found that a sprinkler head had been activated and was in the process of extinguishing a small
fire behind the clerks counter in the market.
Engine 45, which arrived on location at 0707, extinguished the remaining fire and the truck
company ventilated smoke from the market and shut down the sprinkler system. The fire was
declared under control at 0727.
While the crews were cleaning up and putting the sprinkler system back in service, the owner of
the market, Angela Anderson, arrived. She told the Engine Company Captain that she had worked
at the market until midnight. It had been a cold evening and she had plugged in an electric heater
behind the counter to keep warm. She did not remember if the heater was shut off before she
left the market. Ms. Anderson estimated damage to the store contents to be $1,000. The one-story
store had 2,500 square feet of floor space and damage to it was estimated to be $4,000.
During the investigation, the Fire Marshal found a portable heater lying on its side behind the
counter. He determined that the heater ignited a rubber mat on the floor near the cash register.
The automatic shutoff feature on the heater failed to operate when the device tipped over. The
heater was a Heatomatic, model 25, serial number 123666.
Further investigation determined that the hard-wired smoke/heat detector had operated properly and notified the alarm company of the fire. The sprinkler system also had operated properly
- one sprinkler head activated and controlled the fire.
While other firefighters were advancing the hoseline to the seat of the fire, Captain Paul Clarke
(age 37) was injured when he tripped on the hoseline. He suffered a fractured wrist.
Captain Clarkes injury occurred at 0715. Prior to this incident, Clarke and his crew, all career
firefighters usually assigned to suppression, had responded to two other fires during the night and
five other incidents on their shift. After the fire was extinguished, Captain Clarke was taken to
Mercy Hospital. He returned to work the next week for desk duty. The last company cleared the
scene at 0815. An incident number of 9700967 was assigned for this fire.
5-16

MM
NFIRS5
YYYY
Delete
FDID
DD
Incident Date
State
Station
Incident Number
Injured Person
1
2
Male
Female
Exposure
Change
Career
Volunteer
1
2
Fire Service
Casualty
Casualty Number
Casualty Number
First Name
Last Name
MI
Suffix

Age
Midnight is 0000.
Date of Injury
Date of Birth
Time of Injury
OR
In years
G1
1
2
3
4
5
6
7
8
0
H1
Month
Usual Assignment
Suppression
EMS
Prevention
Training
Maintenance
Communications
Administration
Fire investigation
Other
Day
Month
1
2
4
Rested
Fatigued
Ill or injured
Year
Hour
0
U
G4
Other
Undetermined

First aid only
Severe (lost time)
Death
I1
Minute

Taken To
1
4
5
6
7
0
Severity
1
2
3
4
5
6
7
Not transported
Hospital
Doctors office
Morgue/funeral home
Residence
Station or quarters
Other
G5
I3
Object Involved
in Injury
None
Cause of injury
H2
Day
G2
G3
Year
Responses
None
I2
None
Contributing factor
J1
1
2
3
4
5
6
7
8
9
0
U
At FD location
At scene outside
At medical facility
Other
Undetermined
J2

Story of injury
Below grade
J3
65
64
63
61
54
53
49
45
36
35
34
33
32
31
28
27
26
25
24
23
22

Injury Occurred
In aircraft
Complete
Block J4
In rail vehicle
In motor vehicle
In sewer
In tunnel
In structure
In attic
00
Other
In water
UU
Undetermined
In well
In ravine
In quarry or mine
In ditch or trench
In open pit
On steep grade
On ground ladder
On roof
Outside at grade
5-17
J4
Vehicle Type
1
2
3
4
Suppression vehicle
EMS vehicle
Other FD vehicle
Non-FD vehicle
Complete ONLY if
is >60
Remarks

form.
K1
K2
Yes
No
K3
11
12
13
14
15
16
17
10
21
22
23
24
25
26
27
28
20
NFIRS5
Equipment
Sequence
Number
Fire Service
Casualty

11
Burned
12
Melted
21
22
Punctured
23
Scratched
24
Knocked off
25
Cut or ripped
31
32
33
41
Failed under impact
42
43
44
45
46
47
48
49
51
52
Special Equipment
53
61
62
63
64
65
66
67
68
69
71
72
73
74
75
76
77
78
79
70
00
94
95
96
97
00
UU
Undetermined
Helmet
Full face protector
Hood
Ear protector
Neck protector
Other
Protective coat
Protective trousers
Uniform shirt
Uniform T-shirt
Uniform trousers
Coveralls
Apron or gown
Other
Boots or Shoes
31
32
33
34
35
36
37
38
30

Non-safety shoes
Other
41
42
43
44
45
46
40

SCBA closed circuit
Not self-contained
Other
Hand Protection
51
52
53
54
55
50

Work gloves
HazMat gloves
Medical gloves
Other

Flight or jump suit
Brush suit
Exposure suit
Life preserver
Personal lighting
Vehicle safety belt
failed equipment.
5-18
K4

Number
Manufacturer
Model
Serial Number
NFIRS5
Revision 05/01/03
5-19
K1
K2
Yes
No
K3
11
12
13
14
15
16
17
10
21
22
23
24
25
26
27
28
20
NFIRS5
Equipment
Sequence
Number
Fire Service
Casualty

11
Burned
12
Melted
21
22
Punctured
23
Scratched
24
Knocked off
25
Cut or ripped
31
32
33
41
Failed under impact
42
43
44
45
46
47
48
49
51
52
Special Equipment
53
61
62
63
64
65
66
67
68
69
71
72
73
74
75
76
77
78
79
70
00
94
95
96
97
00
UU
Undetermined
Helmet
Full face protector
Hood
Ear protector
Neck protector
Other
Protective coat
Protective trousers
Uniform shirt
Uniform T-shirt
Uniform trousers
Coveralls
Apron or gown
Other
Boots or Shoes
31
32
33
34
35
36
37
38
30

Non-safety shoes
Other
41
42
43
44
45
46
40

SCBA closed circuit
Not self-contained
Other
Hand Protection
51
52
53
54
55
50

Work gloves
HazMat gloves
Medical gloves
Other

Flight or jump suit
Brush suit
Exposure suit
Life preserver
Personal lighting
Vehicle safety belt
failed equipment.
5-20
K4

Number
Manufacturer
Model
Serial Number
NFIRS5
Revision 05/01/03
EXERCISE SCENARIO 5-2: Cary Street Fire

Directions: Read the call information in the exercise below. Use the information provided to complete the entire Fire Service
Casualty Module form and the other required forms. Compare your work to the answers provided in Appendix A. If your answers
are different from the ones provided, read over the Fire Service Casualty Module again.
The Alberta Fire Department (FDID #92188) received a call for a reported house fire at 5 East
Cary Street, Brunswick, Virginia 23351 on May 1, 2005. The dispatcher assigned the incident
(#5433) to Engine 1, Engine 2, and Truck 1 from Shift A, Station 2. The units received the alarm
at 12:53 p.m. and arrived at the scene at 1:05 p.m. Each piece of apparatus was staffed with four
firefighters.
The owner of the single-family dwelling, Mrs. Christy A. Gordon, said that she was warming her
lunch on the stove when the grease from the pan began to burn. The gas stove was a Whirlpool,
Model RF330PXVN, Serial Number F925888840, Year 2000. The fire spread from the pan to
the curtains. She had fallen asleep upstairs and was alerted when the hardwired smoke detector
activated. The flame damage was confined to the kitchen. The 2,000 square feet, two-story home
was filled with smoke in the other rooms. She called 9-1-1. The firefighters extinguished the
fire and removed smoke from the other rooms. The fire was brought under control at 1:25 p.m.
There was $24,000 fire loss to property and $9,600 content loss. The value of the property was
$161,000 and the content value was $80,400. The last unit cleared the scene at 2:40 p.m. FF1
Adam C. Wallner, Badge No. 224, completed the report after returning to Station No.2. Captain
Tonya S. Gordon, Badge No. 105, was the officer in charge. The fire department keeps records on
the location of all responses. The incident was in Census Tract 501.10, District A12.
Mrs. Gordon, 66-year old, white female, was overcome by smoke in her bedroom. She had problems finding the exit because of the smoke. Her injury occurred at 12:50 p.m. Fire department
personnel treated her at the scene. Her injury was considered minor but since she said that she
felt dizzy, a local EMS provider transported her to the Proctor Medical Hospital for observation.
While investigating the incident, Fire Officer Juan M. Mills, a 36-year old, Hispanic, white male,
slipped on debris located on the first floor and sprained his right ankle. His normal assignment
is investigation. He was injured at 2:15 p.m. and treated at the scene by local EMS provider personnel. For precautions, he was also transported to Proctor Medical Hospital for X-rays. He was
treated by the physician and given the okay to return to work. This was his first response in the
24-hour period. Officer Mills is a career member of the department. His badge number is 317.
5-21

MM
Delete
Incident Date
State
Location Type
Station
Incident Number
Exposure
NFIRS1
Number/Milepost
Prefix
Basic
No Activity
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.
Street address
Intersection
In front of
Rear of
Adjacent to
Directions
US National Grid
Census Tract
Street or Highway
Street Type
Suffix
Apt./Suite/Room
City
State
ZIP Code
Cross Street, Directions or National Grid, as applicable
Incident Type
E1
Incident Type
YYYY
Change
FDID
DD
Aid Given or Received
None
Dates and Times
Midnight is 0000
Month
Check boxes if
dates are the
same as Alarm
Date.
Day
Year
Hour
E2
Min
Shifts and Alarms

Local Option
ALARM always required
Shift or
Platoon
Alarm
Alarms
District
ARRIVAL required, unless canceled or did not arrive
1
2
3
4
5
Mutual aid received

Auto. aid received
Mutual aid given
Auto. aid given
Other aid given
Their FDID
Last Unit
Cleared
G1
Resources
Primary Action Taken (1)
G2
Apparatus
Personnel
Suppression
Additional Action Taken (2)
Civilian Fire Cas.4

Fire Service Cas.5
EMS6
HazMat7
Wildland Fire8
Apparatus9
Personnel10
Arson11
Check box if resource counts include aid

received resources.
H1
Casualties
None
Deaths Injuries
Fire
Service
Civilian
H2
1
2
U
Detector
Required for confined fires.
Detector alerted occupants

Detector did not alert them
Unknown
H3
1
2
3
4
5
6
7
8
0
Special
Study Value
Estimated Dollar Losses and Values
LOSSES:
Required for all fires if known.

Optional for non-fires.
Property
Contents
None
PRE-INCIDENT VALUE: Optional
EMS
Other
Additional Action Taken (3)
Special
Study ID#
LAST UNIT CLEARED, required except for wildland fires
Check this box and skip this block if an

Apparatus or Personnel Module is used.
Fire2
Structure Fire3
Local Option
Controlled
Actions Taken
Completed Modules
Special Studies
CONTROLLED optional, except for wildland fires
Their
State
Their Incident Number
E3
Arrival
Property
Contents
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.)
Mixed Use
Property
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
Property Use
None
Structures
Church, place of worship
131
Restaurant or cafeteria
161
Bar/tavern or nightclub
162
Elementary school, kindergarten
213
High school, junior high
215
College, adult education
241
Nursing home
311
Hospital
331
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
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
Outside
Playground or park
124
Crops or orchard
655
Forest (timberland)
669
Outdoor storage area
807
Dump or sanitary landfill
919
Open land or field
931
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
5-22
Look up and enter a

Property Use code and
description only if you
have NOT checked a
Property Use box.
Property Use
Code
Property Use Description

Person/Entity Involved
K1
Local Option
Check this box if same

address as incident
Location (Section B).
Then skip the three
duplicate address
lines.
Business Name (if applicable)
Mr., Ms., Mrs.
First Name
Number
Prefix
Post Office Box
State
Area Code
MI
Phone Number
Last Name
Suffix
Street or Highway
Street Type
Apt./Suite/Room
Suffix
City
ZIP Code
More people involved? Check this box and attach Supplemental Forms (NFIRS1S) as necessary.
Owner
K2
Local Option
Check this box if same

address as incident
Location (Section B).
Then skip the three
duplicate address
lines.
Same as person involved?

Then check this box and skip
the rest of this block.
Mr., Ms., Mrs.
Business Name (if applicable)
First Name
Number
MI
Prefix
Post Office Box
State
Area Code
Phone Number
Last Name
Suffix
Street or Highway
Street Type
Apt./Suite/Room
Suffix
City
ZIP Code
Remarks:
Local Option
Fire Module Required?

Check the box that applies and then complete the Fire Module
based on Incident Type, as follows:
Complete Fire & Structure Modules
Complete Fire Module &
Section I, Structure Module
Basic Module Only
Confined 113118
Complete Fire Module
Mobile property 120123
Complete Fire Module
Vehicle 130138
Complete Fire or Wildland Module
Vegetation 140143
Outside rubbish fire 150155 Basic Module Only
Special outside fire 160
Special outside fire 161163 Complete Fire Module
Crop fire 170173
Buildings 111
Special structure 112
ITEMS WITH A
MUST ALWAYS BE COMPLETED!
More remarks? Check this box and attach Supplemental Forms (NFIRS1S) as necessary.
Authorization
Check box if
same as
Officer in
charge.
Officer in charge ID
Signature
Position or rank
Assignment
Month
Day
Year
Member making report ID
Signature
Position or rank
Assignment
Month
Day
Year
5-23
MM
FDID
DD
YYYY
Incident Date
State
Station
Property Details
B1
C
Not Residential
Incident Number
On-Site Materials
or Products
Change
Exposure
None
Enter up to three codes. Check one box for each code

entered.
On-Site Materials
Storage Use
On-site material (1)
1
2
3
4
U
Bulk storage or warehousing

Processing or manufacturing
Packaged goods for sale
Repair or service
Undetermined
1
2
3
4
U

Repair or service
Undetermined
1
2
3
4
U

Repair or service
Undetermined
Buildings not involved

Number of buildings involved
B3
None
Less than one acre
Acres burned (outside fires)
D
D1
D2
Ignition
E1
Area of fire origin
Heat source
D3
Item first ignited
Check box if fire spread was

confined to object of origin.
Cause of Ignition
Skip to
Section G
Check box if this is an exposure report.
E3
Intentional
Unintentional
Failure of equipment or heat source
Act of nature
Cause under investigation
Cause undetermined after investigation
E2
Factors Contributing to Ignition
3
4
5
None
6
Estimated age of
person involved
Required only if item first

ignited code is 00 or <70
Equipment Involved in Ignition

None
Age was a factor
Factor contributing to ignition (2)
F1
F2
None
Asleep
Possibly impaired by
alcohol or drugs
Unattended person
Possibly mentally disabled
Physically disabled
Multiple persons involved
1
2
Factor contributing to ignition (1)

Type of material first ignited
Human Factors
Contributing to Ignition
Check all applicable boxes
1
2
3
4
5
U
D4
Fire
Complete if there were any significant amounts of

commercial, industrial, energy, or agricultural products or
or materials on the property, whether or not they became involved
Estimated number of residential living units in

building of origin whether or not all units
became involved
B2
NFIRS2
Delete
Equipment Power Source
Male
Fire Suppression Factors
Female
None
Enter up to three codes.
If equipment was not involved, skip to

Section G
Equipment Power Source
Equipment Involved
F3
Brand
Model
Serial #
Equipment Portability
1
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.
Year
H1
Mobile Property Involved
Not involved in ignition, but burned
Involved in ignition, but did not burn
Involved in ignition and burned
None
H2
Fire suppression factor (1)
Mobile Property Type and Make
Local Use
Pre-Fire Plan Available
Some of the information presented in this report may be
based upon reports from other agencies:
Mobile property type
Mobile property make
Mobile property model
License Plate Number
Year
State
Arson report attached

Police report attached
Coroner report attached
Other reports attached
VIN
Structure fire? Please be sure to complete the Structure Fire form (NFIRS3).
5-24

Structure Type
I1
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
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
Fire Origin
J1
I2
Building Status
1
2
3
4
5
6
7
0
U
Under construction
Occupied & operating
Idle, not routinely used
Under major renovation
Vacant and secured
Vacant and unsecured
Being demolished
Other
Undetermined
J3
Number of stories w/significant damage

(25 to 49% flame damage)
None Present
Present
Undetermined
Detector Type
1
2
3
4
5
0
U
Smoke
Heat
Combination smoke and heat
Sprinkler, water flow detection
More than one type present
Other
Undetermined
M1
Number of stories w/extreme damage

Detector Power Supply
1
2
3
4
5
6
7
0
U
0
U
L4
Detector Operation
Fire too small to activate
Operated
Complete
Block L5
Failed to operate
Complete
Block L6
Undetermined
Type of Automatic Extinguishing System

Required if fire was within designed range of AES
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
Width in feet
Type of Material Contributing Most

to Flame Spread
Check if no flame spread OR if
same as Material First Ignited (Block D4,
Fire Module) OR if unable to determine.
K1
Skip to
Section L
Item contributing most to flame spread
M3
K2
Type of material contributing
most to flame spread
L5
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
Presence of Automatic Extinguishing System

None Present
N
Present
1
Complete rest of
Section M
2
Partial System Present
U
Undetermined
M2
BY
Length in feet
Number of stories w/heavy damage

L3
Skip to
Section M
,
Total square feet
Total number of stories

below grade
Fire Spread
(In area of the fire)
NFIRS3
Structure
Fire
OR
Number of stories w/minor damage

Presence of Detectors
L2
Total number of stories at or

above grade
Story of
fire origin
Confined to room of origin

Confined to floor of origin
Confined to building of origin
Beyond building of origin
L1
Main Floor Size
I4
Count the roof as part of the

highest story.
Count the roof as part of the highest story.
If fire spread was confined to object of origin,

do not check a box (Ref. Block D3, Fire Module).
2
3
4
5
Building
Height
Number of Stories Damaged by Flame
Below grade
J2
I3
1
2
3
4
U
L6
Detector Effectiveness
Required if detector operated.
Alerted occupants, occupants responded

Alerted occupants, occupants failed
to respond
There were no occupants
Failed to alert occupants
Undetermined
Detector Failure Reason
Required if detector failed to operate
1
2
3
4
5
6
0
U
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
Operation of Automatic
Extinguishing System
M5
Required if fire was within designed range
Operated/effective (go to M4)

Operated/not effective (go to M4)
Fire too small to activate
Failed to operate (go to M5)
Other
Undetermined
1
2
3
4
0
U
M4
Number of Sprinkler
Heads Operating
Required if system operated
Required only if item

contributing code is 00 or <70.
Reason for Automatic

Extinguishing System Failure
Required if system failed or not effective
1
2
3
4
5
6
7
8
0
U
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
Number of sprinkler heads operating

NFIRS3
5-25
Revision 01/01/06

MM
DD
Delete
FDID
State
Incident Date
Station
Gender
1
Male
First Name
MI
Months (for infants)

Age
E1
Date of Birth
Month
Day
Year
Race
0
U
Other, multiracial
Undetermined
Affiliation
1
2
3
0
E2
1
0
Date of Injury
Hispanic or Latino
Non Hispanic or Latino
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
M1
Midnight is 0000.
Time of Injury
Escaping
Rescue attempt
Fire control
Return to fire before control
Return to fire after control
Sleeping
Unable to act
Irrational act
Other
Undetermined
Month
Day
Year
Human Factors
Hour
None
Severity
Minor
Moderate
Severe
Life threatening
Death
Undetermined
1
2
3
4
5
U
Minute
Factors Contributing
to Injury
None
Enter up to three contributing factors

Check all applicable boxes
1
2
3
4
5
6
7
8
Asleep
Unconscious
Possibly impaired by alcohol
Possibly impaired by other drug
Possibly mentally disabled
Physically disabled
Physically restrained
Unattended person
Location at Time of Incident

1
2
3
4
0
U
Casualty Number
Civilian
EMS, not fire department
Police
Other
Casualty
Number
Female
Ethnicity
1
2
3
4
5
6
7
8
0
U
Change
Suffix
White
Black, African American
Am. Indian, Alaska Native
Asian
Native Hawaiian, Other
Pacific Islander
Activity When Injured
Exposure
Last Name
1
2
3
4
5
OR
Incident Number
Injured Person
2
3
4
5
6
7
8
9
0
U
NFIRS4
Civilian Fire
Casualty
YYYY
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
M2
General Location at Time of Injury
1
2
3
U
In area of fire origin

In building, but not in area
Outside, but not in area
Undetermined
Skip to
Section N
M3
Contributing factor (1)
Story at Start of Incident

Complete ONLY if injury occurred INSIDE
Story at start of incident
M4
Below grade
Story where injury occurred, if

different from M3
M5
Below grade
Specific Location at Time of Injury

Complete ONLY if casualty NOT in area of origin
Skip to
Block M5
Specific location at time of injury
N
01
11
12
21
33
96
98
Smoke only, asphyxiation

Burns and smoke inhalation
Burns only
Cut, laceration
Strain or sprain
Shock
Pain only
Look up a code only if the symptom is NOT found above
Primary Area of Body Injured
Disposition
Transported to emergency care facility
1
2
3
4
5
6
7
8
9
Head
Neck and shoulder
Thorax
Abdomen
Spine
Upper extremities
Lower extremities
Internal
Multiple body parts
Remarks
Local option
NFIRS4
5-26
Revision 01/01/04

MM
NFIRS5
YYYY
Delete
FDID
DD
Incident Date
State
Station
Incident Number
Injured Person
1
2
Male
Female
Exposure
Change
Career
Volunteer
1
2
Fire Service
Casualty
Casualty Number
Casualty Number
First Name
Last Name
MI
Suffix

Age
Midnight is 0000.
Date of Injury
Date of Birth
Time of Injury
OR
In years
G1
1
2
3
4
5
6
7
8
0
H1
Month
Usual Assignment
Suppression
EMS
Prevention
Training
Maintenance
Communications
Administration
Fire investigation
Other
Day
Month
1
2
4
Rested
Fatigued
Ill or injured
Year
Hour
0
U
G4
Other
Undetermined

First aid only
Severe (lost time)
Death
I1
Minute

Taken To
1
4
5
6
7
0
Severity
1
2
3
4
5
6
7
Not transported
Hospital
Doctors office
Morgue/funeral home
Residence
Station or quarters
Other
G5
I3
Object Involved
in Injury
None
Cause of injury
H2
Day
G2
G3
Year
Responses
None
I2
None
Contributing factor
J1
1
2
3
4
5
6
7
8
9
0
U
At FD location
At scene outside
At medical facility
Other
Undetermined
J2

Story of injury
Below grade
J3
65
64
63
61
54
53
49
45
36
35
34
33
32
31
28
27
26
25
24
23
22

Injury Occurred
In aircraft
Complete
Block J4
In rail vehicle
In motor vehicle
In sewer
In tunnel
In structure
In attic
00
Other
In water
UU
Undetermined
In well
In ravine
In quarry or mine
In ditch or trench
In open pit
On steep grade
On ground ladder
On roof
Outside at grade
5-27
J4
Vehicle Type
1
2
3
4
Suppression vehicle
EMS vehicle
Other FD vehicle
Non-FD vehicle
Complete ONLY if
is >60
Remarks

form.
K1
K2
Yes
No
K3
11
12
13
14
15
16
17
10
21
22
23
24
25
26
27
28
20
NFIRS5
Equipment
Sequence
Number
Fire Service
Casualty

11
Burned
12
Melted
21
22
Punctured
23
Scratched
24
Knocked off
25
Cut or ripped
31
32
33
41
Failed under impact
42
43
44
45
46
47
48
49
51
52
Special Equipment
53
61
62
63
64
65
66
67
68
69
71
72
73
74
75
76
77
78
79
70
00
94
95
96
97
00
UU
Undetermined
Helmet
Full face protector
Hood
Ear protector
Neck protector
Other
Protective coat
Protective trousers
Uniform shirt
Uniform T-shirt
Uniform trousers
Coveralls
Apron or gown
Other
Boots or Shoes
31
32
33
34
35
36
37
38
30

Non-safety shoes
Other
41
42
43
44
45
46
40

SCBA closed circuit
Not self-contained
Other
Hand Protection
51
52
53
54
55
50

Work gloves
HazMat gloves
Medical gloves
Other

Flight or jump suit
Brush suit
Exposure suit
Life preserver
Personal lighting
Vehicle safety belt
failed equipment.
5-28
K4

Number
Manufacturer
Model
Serial Number
NFIRS5
Revision 05/01/03

Nfirs Module 5 Fire Service Casualty

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Nfirs Module 5 Fire Service Casualty

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NFIRS 5.

Fire Service Casualty

NFIRS 5.0 Self-Study Program

Pretest #5 - Fire Service Casualty Module

3. The Fire Service Casualty Module is a required NFIRS Module.

NFIRS 5.0 Self-Study Program

Using the Fire Service Casualty Module

Section A: FDID, Incident Number, Exposure

Age or Date of Birth

Date and Time of Injury

Section B: Injured Person

NFIRS 5.0 Self-Study Program

Section C: Casualty Number

Factor Contributing to Injury

Date and Time of Injury

Object involved in injury

Specific Location Where

Activity at Time of Injury

Cause of Firefighter Injury

Report only, including exposure

Number of prior responses

Physical Condition Just Prior to Injury

Activity at time of injury

during past 24 hours

If protective equipment failed and

Age or Date of Birth

Date and Time of Injury

Section G: Usual Assignment, Physical Condition Just Prior

Age or Date of Birth

Physical Condition Just Prior Delete

during past 24 hours

G casualty went after the injury.

Physical Condition Just Prior to Injury

Report only, including exposure

Activity at Time of Injury MM

Date of BirthIdentification Number

Date and Time of Injury

Activity at time of injury

Section H: Primary Apparent Symptom and

Section I: Cause of Firefighter Injury,

Primary Apparent Symptom

Primary apparent symptom

On fire escape/outside stairs

If protective equipment failed and

Nonewas a factor in this injury, please

Factor Contributing to Injury

Primary Part of Body Injured

Primary injured body part

Where Injury Occurred

Specific Location Where

complete the other side of this

Physical Condition Just Prior to Injury

Activity at time of injury

Section J: Where Injury Occurred, Story Where Injury

Primary apparent symptom

Section J is completed to describe the location where the injury occurred.

Returning from incident

Story Where Injury Occurred

Mark the boxes in Block J1 to indicate where the injury occurred.

Injury occurred outside

Injury occurred outside

If protective equipment failed an

If protective equipment failed an

First aid only