1 NFIRS 5 - Fire Service Casualty Module Used to report injuries, deaths or exposures to fire service personnel.

1

NFIRS 5 - Fire Service Casualty

Module

Used to report injuries, deaths or exposures to fire service personnel.

A - Header

Header information is repeated on all modules . . . In an automated system, this information is entered once and imported into all modules

Delete A Change

NFIRS - 5Fire Service

Casualty Station FDID Incident Date

MM DD YYYY

State Incident Number

B - Injured Person

Identifies personal information name gender (sex)

Department type volunteer (include paid-on-call) career

,Acres burned (outside fires)

Not Residential

Number of buildings involved

Estimated number of residential living units in building of origin whether or not all units became involved

B2

B3

Buildings not involved

Less than one acre

None

Property Details

B1

B

1

2First Name Last Name Suffix

Injured PersonBIdentification Number

MI

Male Female

12

Career Volunteer

12

C - Casualty Number

Each fire service casualty is assigned a number begin with 1

,Acres burned (outside fires)

Not Residential

Number of buildings involved

Estimated number of residential living units in building of origin whether or not all units became involved

B2

B3

Buildings not involved

Less than one acre

None

Property Details

B1

B

1

2

Casualty NumberC

Casualty Number

D - Age or Date of Birth

Identifies the age or date of birth of the fire service casualty

,Acres burned (outside fires)

Not Residential

Number of buildings involved

Estimated number of residential living units in building of origin whether or not all units became involved

B2

B3

Buildings not involved

Less than one acre

None

Property Details

B1

B

1

2

In years OR

Date of Birth

Age or Date of BirthD

Day Month Year

Age

E - Date and Time

Identifies the date and time of injury midnight is 0000

Time of Injury Date of Injury

Date & Time of InjuryEMidnight is 0000.

Month Day Year Hour Minutes

F - Responses

Identifies the number of responses that the firefighter made during the previous 24 hours

,Acres burned (outside fires)

Not Residential

Number of buildings involved

Estimated number of residential living units in building of origin whether or not all units became involved

B2

B3

Buildings not involved

Less than one acre

None

Property Details

B1

B

1

2

ResponsesF

Number of prior responses during past 24 hours

G1 - Usual Assignment

Identifies the usual assignment of the injured fire service personnel this might not be

the same as the individual’s activity at the time of injury

Intentional Unintentional Failure of equipment or heat source Act of nature Cause under investigation Cause undetermined after investigation

E1Cause of Ignition

Check box if this is an exposure report.

12345U

Skip to Section G

x

G1Usual Assignment

Suppression EMS Prevention Training Maintenance Communications Administration Fire investigation Other

123456780

G2 - Physical Condition

Identifies the condition of the firefighter prior to the injury

D

Area of fire origin

Heat source

Item first ignited

Type of material first ignited

D1

D2

D3

D4

Ignition

Check box if fire spread was confined to object of origin

Required only if item first ignited code is 00 or < 70

1

2 1 BedroomG2

Physical Condition Just Prior To Injury

RestedFatiguedIll or injuredOther

1230

G3 - Severity

Identifies the severity of the injury Used to report injuries, deaths or

exposures to fire service personnel. Exposure of fire service personnel

to toxic substances or harmful physical agents may be reported

,Acres burned (outside fires)

Not Residential

Number of buildings involved

Estimated number of residential living units in building of origin whether or not all units became involved

B2

B3

Buildings not involved

Less than one acre

None

Property Details

B1

B

1

2

Report only, including exposure First aid only

Treated by physician (no lost time) Moderate (lost time) Severe (lost time) Life threatening (lost time)

Death

SeverityG31234567

G4 - Taken To

Identifies where the fire service casualty was taken after the injury occurred

Intentional Unintentional Failure of equipment or heat source Act of nature Cause under investigation Cause undetermined after investigation

E1Cause of Ignition

Check box if this is an exposure report.

12345U

Skip to Section G

x

G4Taken To

Hospital Doctor’s office Morgue/funeral home Residence Station or quarters Other Not transported

1 4 5 6 7 0 N

G5 - Activity at Time of Injury

Identifies what the firefighter was doing at the time of injury codes are found in the Handbook

or QRG

Intentional Unintentional Failure of equipment or heat source Act of nature Cause under investigation Cause undetermined after investigation

E1Cause of Ignition

Check box if this is an exposure report.

12345U

Skip to Section G

x

Activity at Time of InjuryG5

Activity at time of injury

H1 - Primary Apparent Symptom

Block H1: Primary Apparent Symptom describe most serious apparent injury

Coded field codes are found in Handbook and QRG

Intentional Unintentional Failure of equipment or heat source Act of nature Cause under investigation Cause undetermined after investigation

E1Cause of Ignition

Check box if this is an exposure report.

12345U

Skip to Section G

x

H1

Primary apparent symptom

Primary Apparent Symptom

H2 - Area of Body Injured

Identifies the part of the body which sustained the most serious injury

Primary injured body part or area

H2Primary Area of Body Injured

I1 - Cause of Injury

Identifies the cause of the firefighter injury codes can be found in the

Handbook or QRG

Cause of Firefighter Injury

Cause of injury

I1

I2 - Contributing Factors

Identifies the most significant factor contributing to the injury

Contributing factor

Factor Contributing to InjuryI2

I3 - Object Involved in Injury

Is used to clarify what object contributed to the injuryNone

Equipment Involved In Ignition

Equipment Involved

Brand

Year

F1

Model

Serial #

If equipment was not involved, skip to Section G

6 3 2 Hot Plate

XRS 130

34-2345

1 9 8 5Object involved in injury

Object Involved in InjuryI3

None

J1 - Where Injury Occurred

Describes the location of the fire service casualty at the time of injury

None

Equipment Involved In Ignition

Equipment Involved

Brand

Year

F1

Model

Serial #

If equipment was not involved, skip to Section G

6 3 2 Hot Plate

XRS 130

34-2345

1 9 8 5

Where Injury Occurred J1

Enroute to FD location At FD location Enroute to incident scene Enroute to medical facility At scene in structure At scene outside At medical facility Returning from incident

Returning from med facility Other

1234567890

J2 - Story Where Injury Occurred

Identifies the story above or below grade where the injury occurred Complete only for structures

None

Equipment Involved In Ignition

Equipment Involved

Brand

Year

F1

Model

Serial #

If equipment was not involved, skip to Section G

6 3 2 Hot Plate

XRS 130

34-2345

1 9 8 5

J2Story Where Injury Occurred

Complete for structures only.

Below grade

Story of injury

J3 - Specific Location

Provides additional details on the specific location of the casualty at the time of injury

Complete J4 if casualty was in a vehicle when injured

None

Equipment Involved In Ignition

Equipment Involved

Brand

Year

F1

Model

Serial #

If equipment was not involved, skip to Section G

6 3 2 Hot Plate

XRS 130

34-2345

1 9 8 5

J3Specific Location Complete as

applicable

656463615453494536353433323128272625242322 00

In aircraft In boat or ship or barge

In rail vehicle In motor vehicle In sewer In tunnel In structure In attic In water In well In ravine In quarry or mine In ditch or trench In open pit On steep grade On fire escape/outside stairs On vertical surface or ledge On ground ladder On aerial ladder or in basket

On roof Outside at grade

Other

J4 - Vehicle Type

Complete only if the fire service casualty was in a vehicle at the time of injury

Suppression vehicle EMS vehicle Other FD vehicle Non-FD vehicle

Vehicle TypeJ4

1234

Complete ONLY if Specific Location code is >60

K1 - Protective Equipment

If protective equipment failed and was a factor in this injury, complete Section K

If the answer to K1 is “yes” complete equipment sequence field, and the remainder of the Module

Did protective equipment fail and contribute to the injury?

Please complete the remainder of this form ONLY if you answered YES.

K1 Yes

No

K1 - Equipment Sequence

A unique number assigned to each piece of equipment that failed and contributed to the injury First piece of faulty

equipment is always “001” (consecutively number additional pieces)

,Acres burned (outside fires)

Not Residential

Number of buildings involved

Estimated number of residential living units in building of origin whether or not all units became involved

B2

B3

Buildings not involved

Less than one acre

None

Property Details

B1

B

1

2

Equipment Sequence Number

K2 - Protective Equipment Item

Identifies each piece of equipment that contributed to the injury of the firefighter– If more than one piece

of protective equipment was a factor in the firefighter’s injury, use additional sheets.

None

Equipment Involved In Ignition

Equipment Involved

Brand

Year

F1

Model

Serial #

If equipment was not involved, skip to Section G

6 3 2 Hot Plate

XRS 130

34-2345

1 9 8 5

K2Protective Equipment Item

1112131415161710

Head or Face Protection

Helmet Full face protector Partial protector Goggles/eye protection Hood Ear protector Neck protector Other

K3 - Protective Equipment Problem

None

Equipment Involved In Ignition

Equipment Involved

Brand

Year

F1

Model

Serial #

If equipment was not involved, skip to Section G

6 3 2 Hot Plate

XRS 130

34-2345

1 9 8 5

Describes the most serious problem with the piece of equipment that failed and contributed to the injury

(Partial list)

K4 - Equipment Manufacturer, Model, & Serial Number

Provide detailed information on the specific equipment that failed and contributed to the injury

K4Equipment Manufacturer, Model & Serial Number

Manufacturer

Model

Serial Number

.

Summary The Fire Service Casualty Module

(NFIRS 5) is used to report firefighter injuries or deaths related to an incident Exposure of fire service personnel to

toxic substances or harmful physical agents should be reported, even if no signs or symptoms are present

Fire service casualty information can be used by Health and Safety Officers to reduce risks at incidents

1.Firefighter injured (or killed) during training exercise

2.Firefighter injured (or killed) playing basketball while on duty

Scenarios