Union County Fire Academy
Facility Usage Request Form
Department / Company
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Application Date
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Month
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Day
Year
Date
Applicant Full Name
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Phone Number
*
Please put your direct phone number at your agency or cell phone number.
Format: (000) 000-0000.
Extension
If applicable
Applicant Email
*
example@example.com
Applicant Rank
*
Training Date
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Month
-
Day
Year
Date
Please select Training Date options:
Please Select
I want multiple training dates
I want alternate training dates
None
Additional Training Date/Alternate Training Date
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Month
-
Day
Year
Date
Additional Training Date/Alternate Training Date
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Month
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Day
Year
Date
Additional Training Date/Alternate Training Date
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Month
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Day
Year
Date
Additional Training Date/Alternate Training Date
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Month
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Day
Year
Date
Training Time
*
Please Select
Full Day (0800-1600)
Half-Day Morning (0800-1200)
Half-Day Afternoon (1200-1600)
Evening (1800-2200)
Other (Fire Academy Staff will call to confirm times)
Training Area(s) Requested
*
Burn Building (below queston is required or form will not be accepted)
Classroom (36 Students Max)
Confined Space Simulator (Fire Academy)
Confined Space Simulator (Burn Ground)
Elevator Shaft Area
Fire Extinguisher Simulator
FF Survival Pad (Denver Drill)
Bailout Tower
Fire Extinguisher Pans
Flashover Phase 1
Flashover Phase 2
Force Entry Door Prop
Search & Rescue (non-fire)
Maze Prop
Car Fire Pad
Vehicle Extrication Area
Sprinkler/Standalone Ops.
Outside Burn Pad
Academy Pumper w/ Operator
Self-Rescue Trainer
Other
What Floors/Rooms will you want to burn in for each evolution? Must be filled out if you choose Burn Building or form will not be accepted.
Please Upload Scenarios as Word Document or PDF.
*
Browse Files
Drag and drop files here
Choose a file
Full Scenarios are required to be booked and quoted, otherwise your request will be denied. Please lable file name as "(Town Name) - Scenarios"
Cancel
of
Number of Officers
*
Number of Firefighters
*
Number of Other Personnel
*
0 if Not Applicable
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Union County Fire Academy - Facility Usage Request Form
Department Supplied Instructor Information
Instructor 1
*
Full Name, Rank, Instructor Level, DFS#
Instructor 2
Full Name, Rank, Instructor Level, DFS#
Instructor 3
Full Name, Rank, Instructor Level, DFS#
Instructor 4
Full Name, Rank, Instructor Level, DFS#
Please provide a copy of all current Instructor & Drill Ground certifications for the above listed.
*
Browse Files
Drag and drop files here
Choose a file
Please label file as "(Instructor Name) - Certifications"
Cancel
of
Department Incident Commander
*
Department Safety Officer
*
Number of Department on Scene EMTs
0 if Not Applicable
Fire Academy Personnel Required for Facility Usage
Do you need the Fire Academy to provide instructors?
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Yes
No
2. What services do you want UCFA instructors to provide?
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Critique
Instruct
Monitor
Scenarios:
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Academy Scenarios
Department Scenarios
3. What objectives do you want UCFA Instructors to accomplish?
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Expose F/F's to smoke only
Expose F/F's to fire, heat & smoke
Ladder proficiency
Ventilation proficiency
Hose & Extinguishment proficiency
Search & Rescue proficiency
SCBA proficiency
Other
4. What resources do you need for your training activity?
*
Straw (6 bales per session)
Smoke Generators
Air refill for SCBA
Extinguisher
Ladders
Hose (2.5 is NY Corp.)
Flammable liquids
Force entry props
Hand tools
Other
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Union County Fire Academy - Facility Usage Request Form
Facility Agreements
1. Usage Form must be completed and returned at least 1 month prior to the date of usage.
*
Please Select
I Understand
2. Applicant/Fire Department is required to supply at its own a Rapid Intervention Crew (RIC 2in/2out) on site during live burn training.
*
Please Select
I Understand
3. Applicant/Fire Department is required to supply at least one (1) EMT on site during liveburn training.
*
Please Select
I Understand
4. Applicant/Fire Department is responsible to fully clean, remove all burned hay and wash out burn building at the conclusion of the training session.
*
Please Select
I Understand
5. Applicant/Fire Department is required to supply all it’s own firefighting equipment. If UCFA equipment is requested for use and gets damaged, said applicant will be responsible to repair or replace at their time and cost.
*
Please Select
I Understand
6. Proper attire is a must. No shorts or open toe shoes permitted! Class room dress will be business/business casual or Department uniform.
*
Please Select
I Understand
7. All protective clothing (PPE) must meet O.S.H.A 29 CFR 1910.156
*
Please Select
I Understand
8. No facial hair except mustaches are allowed, at the discretion of UCFA instructors as per OSHA CFR 1910.134and NFPA Std. 1500.5‐3‐10.
*
Please Select
I Understand
9. All SCBA air packs must have a current flow test and any air tank being filled by UCFA staff must have a current hydrostatic test.
*
Please Select
I Understand
10. All Firefighters participating in live fire operations must be Firefighter 1 or better as certified by the NJ Division of Fire Safety unless engaged as part of Firefighter 1 recruit training.
*
Please Select
I Understand
11. The applicant agrees to indemnify and hold harmless the Union County Board of Chosen Commissioners and its employees and agents from any and all claims for any type of injury, property, or other damages resulting from the negligence of applicant’s members or guests.
*
Please Select
I Understand
12. All members are to comply with the rules & regulations set forth by the UCFA. Any person not complying will be revoked from usage with possible permanent suspension of future privileges associated with the UCFA.
*
Please Select
I Understand
13. Applicant’s signature certifies that all participants have a current SCBA Mask fit test and are medically fit to preform fire ground actives.
*
Please Select
I Understand
14. Applicant’s signature also certifies that all participants are covered by the departments Workers Compensation Liability and Medical Insurance.
*
Please Select
I Understand
Cancellation Policy: You must cancel your scheduled use of the Fire Academy at least 48 hours in advance in order to not be charged. Exception to this would be an emergency/fire with in your city or town or extreme weather conditions.
*
Please Select
I Understand
APPLICANT'S SIGNATURE
*
RANK
*
DATE
*
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Month
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Day
Year
Date
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