SAFETY EVENT REPORT

SAFETY EVENT REPORT

For Reporting Events NOT for Requesting Maintenance/Repairs
What type of event are you reporting?
Personal Injury?*

YesNo
Property/Equipment Damage or Loss?*

YesNo
Note: For Personal Injury please Report This To Your Supervisor Immediatly
NFIRS Report #:
BC120XXXXX
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Assigned Station:*
Years of Service?*
Are you Volunteer or Career*

VolunteerCareer
Position:*
Time of Event/Accident*

:HourMinutes
Date of Event/Accident*

MonthDayYear
Date
Event Occurred (At, On, or Enroute To/From):*
Please provide a brief description of the LOCATION where the Event Occurred. (ie: Incident Command Name, "Badger Canyon Fire", Intersection of Bowles & Finley , Station 110, Drill at FTC, PIO Event at Finley Elementary)*
Date of Incident: (if applicable)

MonthDayYear
Date
Time Dispatched: (if applicable)

:HourMinutes
Incident Call Number: (if applicable)
Date Initially Reported:*

MonthDayYear
Date
Officer Reported To:*
Witnessed By:*
Was Medical Treatment Required?*

YesNoN/A
Hospitalized Overnight?*

YesNo
Where was the initial treatment received or provided? (On-Scene, ER, PCP, Other)*
Name of Facility:*
Address of Facility*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Brief Description of Injury, Property/Equipment Damage or Loss:*
Note: If equipment or property needs replaced or repaired also fill out the Maintenance and Supply Request Form.
Cause: (Slip/Fall, Backing, Poor Visibility)*
Was a 360-degree walk around performed?*

YesNo
Apparatus Vehicle ID#:*
Placard ID#:*
Describe the event in full detail:*
Are there any possible contributing factors? (Medications or Fatigue)*
Attach Diagram:

Browse Files

Cancelof
Incident Report Prepared By:*

First NameLast Name
Date*

MonthDayYear
Date

This Section to be Completed by Health and Safety Officer
Date of Incident Review

MonthDayYear
Date
Claim Filed:

YesNo
Claim Type:

BVFFInsuranceLabor and IndustriesOther
Safety Committee Members Present:
Summary of Root Cause: (For Accident Investigation Use Only)
Should be Empty: