RF14B

This is an experimental electronic lodgement application of the new
Incident Report - RF_14B for STRUCTURAL, HAZARDOUS MATERIALS, MOBILE PROPERTIES, RESCUE and EVACUATION 
form designed , written and published by G.Maguire ( in 1998 by the way ) for the Southeasters website.
ONE day the "online lodgement process" may become a reality.
However, until the powers that be 'get with it', so to speak, you will still have to push a pen and use snail mail for your
incident reports.
Feel free to fill out a dummy report and a rough copy will be returned immediately.
Don't forget your email address so I can bounce you back the actual copy that would come to your mailbox and also the
RFS mailbox if the script were re-configured.
Submit your report via the Submit button at the end of the form.
__________________________________________________________________________________________________________

Year :


Filing officer to provide the following contact information:

First name
Last name
Title
Brigade
E-mail

Brigade Number... ?


Incident number ... ?


Date of Incident ... :

-- dd/mm/yy

Time of callout ... :

-- 24 hour clock

A9    Method of notification :


Describe other :

 

A10    Agency/person who raised the alarm :


Describe other :


A13    Location of Incident :

Latitude <South> ... ?


Longitude <East> ... ?


 

A14    Occupant contact information:

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

A19    Type of property on which the incident took place :

 

Describe other :

A21    Type of owner :


Describe other :


A22    Type of occupant :


Describe other :


A23    Type of Incident - Structural Fire :


Describe other :


          Type of Incident : Mobile property fire


Describe other mobile property fire :


          Type of Incident : Rescue and emergency medical service


          Type of Incident : Hazardous conditions ( not a fire )


          Type of Incident : Assist other agencies

A24    Type of action taken :


Describe other :


A37    Were you delayed arriving at the fire scene ?


If Yes , why ?


Describe other :

A39    Were self contained breathing apparatus used ?

A42    Did you encounter any problems ?


If Yes please specify :


Describe other :


Equipment problems :


Describe other :


Response problems


Describe other :


Responding brigades names and/or numbers :


D1    Number of brigade personnel injured ... ?


D2    Number of other personnel injured ... ?


D3    Number of brigade personnel fatalities ... ?


D4    Number of other personnel fatalities ... ?


A56    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 :

E1    Room or area within property where fire originated :

E2    Occupant of ignition area :

Describe other :

E4    Could the cause of the fire be identified ?


If Yes , What :


Describe other :

E8    Type of equipment, if any, that provided the heat that caused the fire :

E9    Year of manufacture :


E10    Make :


E11    Model :


E12     Serial number :

 

E13    Voltage :


F1    Who was primarily responsible for extinguishing the fire ?


Describe other :


F2    Who were the first to take action to extinguish the fire ?


Describe other :

 

F3     Method of initial attack to extinguish fire :

         Manual firefighting aids :


        Portable fire extinguisher :

Describe other :

F5     Major method of extinguishment :

         Manual firefighting aids :


        Portable fire extinguisher :

Describe other :

F6    Major extinguishing medium :

Describe other :

F16    Water supply method :

Describe other :

H1      Estimated dollar loss :

H1      Estimated potential loss :

H5      Was the property insured ?

H6     Total number of mobile properties involved in the fire (if applicable) :

H7      Total number of structures involved in the fire )if applicable) :


Structural Fires Only

K3    Building Dimensions ( the ground floor area of the building ) :

K5     Internal wall linings :

Describe other :

 

K6      Ceiling linings :

Describe other :

K22     Extent of extinguishing medium damage :

Describe other :

K24    Was there a smoke alarm within the structure ?

If there was a smoke alarm located within the structure , was :

Alarm power supply :

Operation of smoke alarm :

Effectiveness of smoke alarm :

Describe other :

Reason for smoke alarm failure if known :

Describe other :

Estimated percentage of property involved on arrival :

%

Estimated percentage of property saved due to firefighting operations :

%

Extinguishment time :

           hours   mins   (24 hour clock)

Mobile Properties Only

J1       Mobile property type :

Describe other :

J2    Year of manufacture :

J3    Make :

J4    Model :

J5    Body Serial number :

J6    Registration Number :
        
         

J7    Australian State,Territory of registration :

Hazardous Materials Incident Only

C1      Type of Hazardous Material incident :

Describe other :

C2      UN number/substance identification number :

C3      Chemical Name :

C4      Trade name :

C5      State of Substance :

Describe other :

C6      Quantity Present :

C8      Type of Container :

C10     Cause of Release :

Describe other :

C13     Primary Action Taken :

Describe other :

C18     Predominant Wind Force During the Incident :

C19     Wind Direction :

C20     Temperature :

C24     Name of the Company that transported the material (if applicable) :

Rescue and Evacuation Only

D5    Number of personnel rescued by reporting authority :

         

D6      Authority effecting rescue :

Describe other :

D7      Reason for rescue :

Describe other :

D8      Number of personnel evacuated :


D9      Date evacuation completed :


D10     Time evacuation completed :

.. 24 hour clock

D11     Evacuation Problems (the most significant factor affecting the evacuation) :

Describe other :

D14     Authority effecting evacuation :

Describe other :

 

Is any further action required ?


Describe other :


Was any private equipment damaged ?


If Yes please specify :

Enter the date of filing this report ... :

-- dd/mm/yy

 

This form and the processing script are
copyright © G.Maguire December 1998
All rights reserved, but permission will willingly
be given to the RFS free of charge if they
wish to use it.