FIRE FATALITY REPORT Reporting Agency Phone Agency Name ( ) Reporting Person Title E-Mail Address Victim Information Date of Birth Name (First Name, Middle Initial, Last Name) Gender Age Male Female Cause of Death Date of Fatality Smoke Inhalation Thermal Burns Other: Incident Information Incident Number Date of Fire Time of Day a.m. p.m. Incident Address City County ZIP Occupancy Dollar Loss $ Rented Owned Other: Occupancy Type (check all that apply) Origin of Ignition Human Factors (check all that apply) Single Family Dwelling Business/Church Intentional Asleep Multi-Family Dwelling Detached Garage/Shed Unintentional Unconscious Manufactured Home Recreational Vehicle Act of Nature Possibly Impaired by Alcohol/Drugs Duplex Vehicle Cause Undetermined Unattended/Unsupervised Person Townhouse Outdoor Cause Under Investigation* Possibly Mentally Disturbed * Please provide final outcome Hotel/Motel Physically Disabled report to State Fire Marshal’s Age Was a Factor Office Homicide Other: Suicide Source of Ignition Smoke Alarm/Detectors (check all that apply) Candle Fireworks Part 1: Present Not Present Unknown Home Heating Part 2: Operational Not Operational Unknown Child With Access to Ignition Device Cooking Vehicle Collision Power Source Drug Manufacturing/Lab Undetermined Heat Source Electrical Appliance Smoking Battery Operated Hard Wired Unknown Electrical Distribution Brand of cigarette, if known: Fire Sprinklers (check all that apply) Part 1: Present Not Present Other: Part 2: Activated Not Activated Narrative/Circumstances Attach additional narrative sheets, as needed REMIT INFORMATION IN WRITING OR VERBALLY WITHIN 48 HOURS TO THE E-MAIL, FAX NUMBER, OR ADDRESS LISTED ABOVE.
FIRE FATALITY REPORT Reporting Agency Agency Name Phone ( ) Reporting Person Title E-Mail Address Victim Information Name (First Name, Middle Initial, Last Name) Gender Age Date of Birth Male Female Cause of Death Date of Fatality Smoke Inhalation Thermal Burns Other: Incident Information Date of Fire Time of Day Incident Number a.m. p.m. Incident Address City County ZIP Occupancy Dollar Loss Rented Owned Other: $ Occupancy Type (check all that apply) Origin of Ignition Human Factors (check all that apply) Single Family Dwelling Business/Church Intentional Asleep Multi-Family Dwelling Detached Garage/Shed Unintentional Unconscious Manufactured Home Recreational Vehicle Act of Nature Possibly Impaired by Alcohol/Drugs Duplex Vehicle Cause Undetermined Unattended/Unsupervised Person Townhouse Outdoor Cause Under Investigation* Possibly Mentally Disturbed Hotel/Motel * Please provide final outcome report to State Fire Marshal’s Office Physically Disabled Age Was a Factor Other: Homicide Suicide Source of Ignition Smoke Alarm/Detectors (check all that apply) Candle Fireworks Part 1: Present Not Present Unknown Child With Access to Ignition Device Home Heating Part 2: Operational Not Operational Unknown Cooking Vehicle Collision Drug Manufacturing/Lab Undetermined Heat Source Power Source Electrical Appliance Smoking Battery Operated Hard Wired Unknown Electrical Distribution Brand of cigarette, if known: Fire Sprinklers (check all that apply) Other: Part 1: Present Not Present Part 2: Activated Not Activated Narrative/Circumstances Attach additional narrative sheets, as needed REMIT INFORMATION IN WRITING OR VERBALLY WITHIN 48 HOURS TO THE E-MAIL, FAX NUMBER, OR ADDRESS LISTED ABOVE.
420198_Fire_Fatality_Report_8-18.docx