Year :

Filing officer to provide the following contact information:

First name
Last name
Title
Brigade
E-mail

Brigade Number... ?

Incident number ... ?

Date of Incident ... :

Time of callout ... :

-- 24hr clock

Type of Incident:

Controlled burn Uncontrolled burn Other

Describe other :

Method of notification :

Phone call direct to brigade
Verbal report to brigade
000 - from Firecom
Other

Describe other :

Agency/person who raised the alarm :

Resident,occupier,employee of property affected : Traveller, passerby, neighbour Fire Service personnel Fire lookout Aircraft spotting, observation Police Ambulance Air traffic control Other

Describe other :

Occupant contact information:

Name
Street address
Address (cont.)
City
State
Postcode
Lot number
RP number
Shire name

Type of owner :

Undetermined Private Local Government State Government Unoccupied Other

Describe other :

Type of occupant :

Undetermined Private Local Government Commonwealth Government Unoccupied Other

Describe other :

Type of Incident :

Forest or bush fire (more than one hectare) Scrub or bush fire and grass mixture Grass fire Cultivated grain or crop fire Cultivated orchard or vinyard fire Cultivated trees or nursery stock fire Small vegetation fire (less than one hectare) Abandoned outside rubbish, refuse or waste fire Garbage dump or sanitary landfill fire Other

Describe other :

Type of action taken .. Extinguishment

Construct fire breaks Back burning Other

Describe other :

Date incident made safe ... :

-- dd/mm/yy

Time incident made safe ... :

hrs

Maximum number of fire personnel at the scene ... ?

Maximum number of vehicles used ... ?

Maximum number of Aircraft used ... ?

Direction of prevailing wind

Velocity of prevailing wind :

still light moderate strong

Relative humidity :

Were you delayed arriving at the fire scene ?

yes no

If Yes , why ?

not applicable Appliance attending another incident Appliance attending another incident Appliance failure Delayed attendance of volunteers Call not properly transmitted or received Traffic delay on route Difficulty locating incident / wrong address etc. Other

Describe other :

Did you encounter any problems ?

Yes No

If Yes please specify :

Lack of on scene information because of :

not applicable Lack of co-operation from owner/occupier Non attendance of support agency Delay in relaying information to the scene Communication problems (language,verbal) Inadequate or poor technical advice Lack of water Poor radio communications Other

Describe other :

Equipment problems :

not applicable Inadequate equipment Insufficient equipment Equipment failure Delay in obtaining equipment Other

Describe other :

Response problems

not applicable Insufficient information given to emergency response authority Inadequate response proceedures Insufficient manpower responded Difficulty gaining access to incident scene Other

Describe other :

Responding brigades names and/or numbers

Did any of the following organizations attend ?

Electricity
Gas
Water
Police
Ambulance
SES
Environment protection agency
Volunteer rescue service
Charitable support agencies
Government welfare agencies
Other

Describe other :

Could the cause of the fire be identified ?

Yes No

If Yes , What :

not applicable Equipment exhaust Cigarette , cigar or pipe Match Lighter Camp fire Lightning Heat spreading from another hostile fire Other

Describe other :

Who was primarily responsible for extinguishing the fire ?

Volunteer brigade Permanent , full time brigade Composite permanent and auxilliary brigade Auxilliary brigade Land management authority (DNR,Railways etc. Defence force personnel Civilians Other

Describe other :

Who were the first to take action to extinguish the fire ?

Volunteer brigade Permanent, full time brigade Composite permanent and auxilliary brigade Auxilliary brigade Land management authority (DNR,Railways etc.) Defence force personnel Civilians Other

Describe other :

Major method of extinguishment :

Self extinguished beaters garden hose Rake Hoes Shovels Portable fire extinguisher Knapsacks Appliance hose lines with water carried in appliance tanks Reticulated water Other

Describe other :

Major extinguishing medium:

Water only Water with wetting agent or retardant Other

Describe other :

Water supply method:

Static supply(dam,river,tank) Reticulated supply Water transported by brigade vehicles Water transported by other vehicles Other

Describe other :

Estimated date that ignition occurred :

-- dd/mm/yy

Estimated time that ignition occurred :

-- 24 hr clock

Total area of bush , forest , grass or crops burnt :

-- Hectares

Fire restrictions :

No fire restrictions Fire restrictions in force but not total ban Fire restrictions and a total ban in force State of Fire Emergency Other Restrictions

Describe other restrictions:

Fire danger rating at time of outbreak :

Permit :

Permit issued, conditions complied with Permit issued, conditions not complied with NO permit issued, but was required No permit required Permit not applicable

Vegetation type :

Pine plantation Native hardwood forest Cypress forest Savannah (open forest and grass country) Wallum and swamp Improved grasslands , grassed areas, grazing Native grasslands (may be grazed) Crops Orchards and vinyards Vegetation type undetermined Other

Describe other :

Number of houses damaged ... ?

Number of buildings damaged

Number of vehicles damaged

Number of kms fence damaged

Number tonnes of fodder or hay lost

Number sheep lost

Number cattle lost

Number horses lost

Number other livestock lost

Losses machinery

Was fire prevention effective ? Why :

not applicable Firebreak mechanical (ploughed,graded) Firebreak chemical (poisoned) Firebreak cut, slashed, mown Firebreak natural (bare earth, rock) Fuel reduced area, previous fuel reduction burn Fuel reduced area , previous wildfire Other

Describe other :

Was fire prevention NOT effective ? Why :

Describe other :

Estimated dollar loss :

Estimated maximum potential loss :

Number of brigade personnel injured ... ?

Number of other personnel injured ... ?

Number of brigade personnel fatalities ... ?

Number of other personnel fatalities ... ?

Is any further action required ?

not applicable Investigation No further action required Other

Describe other :

Was any private equipment damaged ?

No Yes

If Yes please specify :

Enter the date of filing this report ... :