Professional Documents
Culture Documents
0 Self-Study Program
Objectives
After completing the Civilian Fire Casualty Module the student will be
able to:
1. Describe when the Civilian Fire Casualty Module is to be used.
2. Demonstrate how to complete the Civilian Fire Casualty Module, given
the scenario of a hypothetical incident.
4-1
Table of Contents
Pretest #4 - Basic Civilian Fire Casualty Module. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4-3
Using the Civilian Fire Casualty Module . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4-4
Section A: FDID, State, Incident Number, Incident. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4-4
Section B: Injured Person. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4-4
Section C: Casualty Number. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4-4
Section D: Age or Date of Birth. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4-5
Section E: Race and Ethnicity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4-5
Section F: Affiliation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4-5
Section G: Date and Time of Injury. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4-6
Section H: Severity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4-6
Section I: Cause of Injury. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4-6
Section J: Human Factors Contributing to Injury . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4-7
Section K: Factors Contributing to Injury . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4-7
Section L: Activity When Injured . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4-7
Section M: Location at Time of Incident, General Location at Time of Injury,
Story at Start of Incident, Story When Injury Occurred, and
Specific Location at Time of Injury. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4-8
Section N: Primary Apparent Symptom. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4-9
Section O: Primary Area of Body Injured. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4-9
Section P: Disposition. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4-10
SUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4-10
EXAMPLE: Burn Victim. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4-11
EXERCISE SCENARIO 4-1: Market Street Fire. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4-13
EXERCISE SCENARIO 4-2: Cary Street Fire. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4-16
(a) True.
(b) False.
2. The Civilian Fire Casualty Module can be used for civilian injuries resulting from an automobile
accident with no associated fire.
(a) True.
(b) False.
(a) True.
(b) False.
4. The Civilian Fire Casualty Module can be used to report exposures to hazardous substances.
(a) True.
(b) False.
5. The Civilian Fire Casualty Module is completed for each civilian casualty reported in H1 of the
Basic Module.
(a) True.
(b) False.
4-3
he Civilian Fire Casualty Module is used to record any civilian (nonfire service) casualty associated with a fire-related incident. When you enter information on Block H1 of the Basic Module,
the completion of this Module is required.
NOTE: A casualty is a person who dies or is physically injured as the direct result of a fire-related incident. In this circumstance
the term civilian includes, but is not limited to, private citizens, emergency medical responders (not part of the fire department),
utility workers, and police. Deaths also include people who die within 1 year of the incident because of injuries sustained from
the incident. In this case, it is important to submit a change to the Civilian Fire Casualty Module for that incident.
DD
YYYY
Delete
FDID
State
Incident Date
Incident Number
Station
Exposure
Change
NFIRS4
Civilian Fire
Casualty
Casualty
Injured Person
B information
C from
The
contained in Section A of the Civilian Gender
FireMale
Casualty
Module is drawn
Section
Number
1
2
Female
A of the Basic Module. Use the data in the Basic Module to help you supply the requested informaFirst Name
MI
Last
Name
tion.
If you are using an automated
system
the data need to be entered onlySuffix
once, thenCasualty
theyNumber
will be
transferred automatically into other
modules that use the data.
Race
FDID
E1
1
2
3
4
State
5
White
Black, African American
MM
DD
YYYY
Am. Indian, Alaska Native
Asian
Incident Date
Native Hawaiian, Other
Pacific Islander
Month
Other, multiracial
Undetermined
Injured Person U
Day
Year
First Name
E2
Affiliation
1
2
3
Station
0
Civilian
EMS, not fire department
Police
Incident Number
Other
OR
Date of Birth
Ethnicity
1
0
1
Exposure 2
3
Midnight is 0000.
of Injury
4
G Date and TimeGender
5
Date of Injury
Time of Injury
1
Male 2
Female U
Hispanic or Latino
Month
Last Name
Non HispanicMIor Latino
Day
Year
Hour
Severity
NFIRS4
Delete
Minor
Civilian Fire
Moderate
Casualty
Change
Severe
Life threatening
Casualty
Death C
Number
Undetermined
Minute
Suffix
Casualty Number
E1 andRace
Section
B ofisInjury
used to enter the first
name,
middle initial,
and KanyFactors
suffixContributing
(i.e., Jr., Sr., and
III)
Affiliation
Factors
None
None
I Cause
JlastHuman
1
White
D Age or Date of Birth
F
H Severity
Contributing to Injury 1
to
Injury
Civilian
for
casualty.
2
Black, African American
Exposed
to fire products including flame
1 the
heat, smoke, and gas
Months (for infants)
Enter up
to three
contributing factors
EMS, not
fire
department
Minor
3
Police
4
Asian
Exposed
to toxic fumes
other thanwhether
smoke
2
Boxes
areAgeavailable
to indicate
the
casualty
is male or
female.
You are required to 12fill inModerate
the
Check
all applicable
boxes
0
Other
Native Hawaiian, Other
5
3
Jumped in escape attempt
Contributing factor (1)
Severe
3
1
Asleep
Pacific
Islander
gender
field.
Midnight is 0000.
Fell, slipped, or OR
tripped
4
Life threatening
4
2 multiracial
Unconscious
Other,
G Date and Time of Injury
0
5
Caught or trapped
Death
5
3
Possibly
impaired
by
alcohol
U
Date
of
Birth
Undetermined
Date
of
Injury
Time
of
Injury
Structural collapse
6
Contributing factor (2)
Undetermined
U
4
Possibly
impaired
by
other
drug
7
Struck by or contact with object
Ethnicity
DD
YYYY
PossiblyNFIRS4
mentally disabled
E2 1 5 Hispanic
Delete
Overexertion
or
strain
8
or Latino
Civilian
Fire
Month
Day
Year
Month
Day
Year
Hour
Minute
6
Physically
disabled
MultipleIncident
causes
9 Station
Number
ent Date
Exposure
Hispanic or
Latino
0 7 NonChange
Casualty
Contributing factor (3)
Physically
restrained
Other
0
8
Unattended person
U
Undetermined
of Injury
Human Factors
Contributing
None
Casualty
Gender
None
I Cause
K Factors
C J Number
Contributing to Injury
to Injury
1 Injured
2 products
Time of Incident
Male
FemaleLocation
1 When
Exposed
to fire
includingatflame
Activity
Story
at
Start
of
Incident
M1 1 In area of origin and not involved
L
M3 Complete ONLY if injury
Enter up to three contributing factors
heat, smoke, and gas
occurred INSIDE
2
Not
in
area
of
origin
and
not
involved
Exposed to toxic fumes other
than smoke Check allNumber
2
applicable boxes
MI
Last Name
Story at start of incident
3 SuffixNot in area of Casualty
Below grade
origin,
but
involved
1
Escaping
3
Jumped in escape attempt
Contributing factor (1)
4
In area of origin1and involved
Asleep
2
Rescue
4 attempt
Fell, slipped, or tripped 0
Other location 2
Race
Unconscious
3
1
Fire control
M4 Story Where Injury Occurred
5 Affiliation
Caught or trapped
U
UndeterminedSeverity
3
Possibly
impaired
by alcohol
4
White
F 6 to fire
Return
before
control
H
Structural
collapse
Story where injury occurred,
if
1 fire
Civilian
Contributing
factor (2)
Below grade
4 TimePossibly
impaired by
other
5
Black, African American
Return
after
control
different
from drug
M3
General
Location
at
of
Injury
7 to
Struck
by
or
contact
with
object
M2
2
EMS, not fire department
5
Possibly
mentally
disabled
Am. Indian, Alaska Native
6
Sleeping
8 3 Overexertion
or
strain
Minor
1
Police
6
Physically
Asian
7
Unable
act
Skipdisabled
to
9 to
Multiple
1
In area of fire
at Time of Injury
Moderate
2 origin
Section
N
0 act
Othercauses
Contributing factor (3)
7
Physically
restrained
Native Hawaiian, Other
M5 Specific Location
8
Irrational
0
Other
2
In
building,
but
not
in
area
Severe
3
Pacific Islander
Complete ONLY if casualty NOT in area of origin
8
Unattended
person
0
Midnight is 0000.
OtherU
Skip
to
Outside, but4not inLife
area
and Time of Injury3
threatening
Block M5
Other, multiracial U
G DateUndetermined
Undetermined
U
Undetermined
Death
5
Undetermined
Date of Injury
Time of Injury
Specific location at time of injury
Undetermined
U
at Time of Incident
Story at Start of Incident
Ethnicity
M1 Location
L Activity When Injured
M3 Complete
1
In area of origin and not involved
2
ONLY if injury occurred INSIDE
Primary
Apparent
1
Hispanic or Latino
Month
Day
YearSymptom Hour
Minute
2
NotArea
in area
originInjured
and not involved Disposition
Primary
ofofBody
N
O
P
Story at start of incident
3
Below grade
Non Hispanic or Latino
Not in area of origin, but involved
0
1
Escaping
4
In area of origin and involved
01
only,attempt
asphyxiation
2Smoke
Rescue
Each casualty is given a number. The numbers are assigned consecutively starting with one (001) and
continuing, based on how many civilians are injured or killed.
4-4
MM
A
FDID
State
DD
YYYY
Incident Date
Incident Number
Station
Gender
1
Male
Injured Person
MI
E1
Date of Birth
Month
Day
Year
Female
Suffi
Race
White
Black, African American
Am. Indian, Alaska Native
Asian
Native Hawaiian, Other
Pacific Islander
0
U
Other, multiracial
Undetermined
E2
Last Name
1
2
3
4
5
OR
Exposure
Affiliation
1
2
3
0
Civilian
EMS, not fire department
Police
Other
Date of Injury
Midnight is
Time of Injury
Ethnicity
1
0
Hispanic or Latino
Non Hispanic or Latino
Month
Day
Year
Hour
Minute
Human Factors
of Injury
Enter either the age or the date of birthI of Cause
the casualty
in Section D. Do not Jenter
both. The number None K Factor
Contributing to Injury
to Inju
Exposed to
fire
products
including
flame
1 provided
associated with the age is assumed to beMM
in
years
unless
the
months
box
is
marked.
The
age
DD
YYYY
NFIRS4
Enter up to three c
heat, smoke, and gas
Delete
A
Civilian Fire
should be recordedFDID
in months only
forIncident
infants
whotoare
than
1 than
year
old
at the timeExposure
of
Exposed
toxicless
fumes
other
smoke
2
boxesinjury.
Incident
Number Check all applicable
Date
Station
State
Casualty
B
A
Injured Person
FDID
First Name
B
D
3
Jumped in escape attempt
1
Fell, slipped, or tripped
4
2
5
Caught
or
trapped
MM
DD
YYYY
Gender 3
Structural collapse
6
1
Male4
7 Date
Struck by or contact Station
with objectIncident Number
Incident
5
Overexertion or strain
8
6
MI causes
Last Name
Multiple
9
7
Other
0
Gender 8
Undetermined
U
Race
E1
1
Male
Affiliation
Injured Person
Age or Date of Birth
1
2
3
4
15 1
21
320
43U
54
65 2
White
Change
Contributing factor (
Asleep
Unconscious
Casualty
NFIRS4
Possibly impaired by alcohol
C Number
Delete
Contributing
Civilian
Firefactor (
2 Possibly
Femaleimpaired by other drug
Exposure
Casualty
Change
Possibly
mentally disabled
Physically disabled
Casualty Number
Suffix
Contributing factor (
Physically restrained
Casualty
Unattended person
C Number
2
Female
Severity
1 Location
Civilian
at Time of Incident
Story at Start
Casualty
Number
Suffix
M3 Complete
notof
fire
department
1 EMS,
In area
origin
and not involved
Am. Indian, Alaska Native
ONLY if injur
Months (for infants)
Minor
1
3
Police
2
Not in area of origin and not involved
Asian
Age
Story
at
start
of
incident
Moderate
2
RaceHawaiian, Other
Not in area of origin, but involved
0 3 Other
E Escaping
Native
Affiliation
Severity
Date of Birth
4
Severe
In area of origin and involved
3
Rescue
attempt
Pacific Islander
White
D Age orOR
F
Midnight is 0000. H
Other of
location
Time
Injury
Life threatening
1 0and
Civilian
4
Fire
control
Black,
African
American
Other,
multiracial
G Date
M
4 Story Where I
U
Undetermined
Death
2
EMS,
not
fire
department
5
Return
to fire
before
control
Am.
Indian,
Alaska
Native
Date of Birth
Undetermined
Date of Injury
Time of Injury
Story where injury occurred
Months (for infants)
Minor
1
3
Police
Undetermined
Return
to fire after control
Asian
different from M3
Location at Time of Injury U
Ethnicity
Age
M02 General
Moderate
2
Other
E 1Sleeping
Native Hawaiian, Other
Hispanic
or
Latino
Month
Day
Year
Severe
3
Month
Day
Year
Hour
Minute
1
Pacific Islander
7
Unable
to act
Midnight is 0000.Skip to
OR
1
area
of fire
origin
Specific Loca
Non Hispanic or Latino
0
and
Time
of Injury
Life
Section
4N M
5 threatening
80
Irrational
act
Other, multiracial
G 2Date In
In building, but not in area
Death
5
Complete
ONLY if cas
0U
Date of Birth
Other
Undetermined
Date of Injury
Time of Injury
Skip to
3
Outside, but not in area
Undetermined
Block U
M5
U
Undetermined
Human
Factors
Factors
Contributing
Cause
of
Injury
None
Ethnicity
None
I
K to Injury
U
Undetermined
E2 1 Hispanic orJ Latino
Specific location at tim
Contributing to Injury
Month Exposed
Day
Month
Day
Year
Hour
Minute
1
to Year
fire products including
flame
Enter up to three contributing factors
Non Hispanic or Latino
0
heat, smoke, and gas
Primary Apparent Symptom
Disposition
Primary
Area
of Body Injured P
Exposed to toxic fumes other
than
smoke
2
N
O
Check all applicable boxes
Jumped
in
escape attempt
3
Human
Factors
Factors
Contributing
Cause
of
Injury
None
Contributing
factor
(1)
01
SmokeJ
only, asphyxiation
None
I4 Fell, slipped, or tripped
1
Asleep
2
K to Injury
Transported
t
Contributing
to Injury
11
Burns and
inhalation
2 smoke
Unconscious
1
Head
15DD Exposed
to fire products including
flame
Caught
MM
YYYY or trapped
NFIRS4 Enter up to three contributing factors
12
Burns
only
3
Possibly
impaired
by
alcohol
Delete
2
Neck and shoulder
heat,
smoke,
and gas
A
6
Structural
collapse
Civilian
Fire
Contributing factor (2)
21
Cut, laceration
4
Possibly impaired by other
drug
Remarks
3
Thorax
Exposed
fumes
other
than
Incident
Numbersmoke
Struck bytoortoxic
contact
with
object
7
Incident Date2
Check Exposure
all applicable boxes
FDID
Station
State
Casualty
Change
33
Strain or
sprain
5
Possibly
mentally
disabled
4
Abdomen
Jumped
in
escape
attempt
38
Overexertion or strain
Contributing
factor
(1)
Asleep
96
Shock 16
Physically disabled
5
Spine
49
Fell,
slipped,
or tripped
Multiple
causes
27
Unconscious
98
Pain only
factor (3)
Physically restrained 6Casualty
UpperContributing
extremities
Caught
or
trapped
5
0
Other
Gender
38
Possibly
impairedC
by alcohol
B Injured Person
Unattended
7Number
Lower extremities
Look up a code only if the symptom
is NOT
found above person
6U
Structural
collapse
Undetermined
Contributing factor (2)
1
Male 2 4 Female
Possibly impaired by other
drug
8
Internal
Struck by or contact with object
7
5
Possibly
mentally
disabled
9
Multiple
body parts
8
Overexertion or strain
Primary apparent
symptom 6at Time
of Incident
Physically
When
Injured
Story at Start of Incident
First Name
Last Name
Suffix disabled Casualty Number
M1 Location
Multiple
causes
9L MI Activity
M
3
1
In area
and not
involved
Contributing
(3) occurred INSIDE
Complete
ONLYfactor
if injury
7 of origin
Physically
restrained
0
Other
2
Not8in areaUnattended
of origin andperson
not involved
Race
Story
at
start
of
incident
U
Undetermined
Below grade
Not in area of origin, but involved
E1 1 Escaping
Affiliation 3
Severity
4
In area of origin and involved
1
White
D Age or Date of Birth
F
2
Rescue attempt
H
0
1
Civilian
Other location
Story at
Where
Occurred
2
Black,
African
American
3
Fire control
Location
at Time of Incident
M34 Story
Activity
When Injured
StartInjury
of Incident
Undetermined
MEMS,
1 Unot fire
L Indian,
M
2
department
3
Am.
Alaska
Native
4
Return
to fire
before control
1
In area of origin and not involved
Complete
ONLY
if
injury
occurred
INSIDE
Months (for infants)
Minor Story where injury occurred, if
1involved
Police
Below grade
2General
4
Asian
Not Location
in area of origin
andof
not
5
Return to fire after control3
different from M3
at Time
Injury
Age
Moderate
2
M
2
Story
at
start
of
incident
0
Other
3
Below grade
Not in area of origin, but involved
16
Native
Hawaiian, Other
Escaping
5
Sleeping
Severe
3
4
In area of origin
and involved
Pacific
Islanderto
27
Rescue
attempt
Midnight is 0000.
Unable
act
Skip to
OR
1 Time
0In area
ofOther
Injury
Life
of fire
origin
Specific
Location
Time of Injury
4 Section
location
N threatening
Where
Injury at
Occurred
38
Fire
control
Other,
multiracial
G Date and
0
M5 Story
Irrational
act
UIn building,
Undetermined
2
Death 4 Complete ONLY if casualty NOT in area of origin
but
not
in
area
5
U
40
Date of Birth
Undetermined
Return
to
fire
before
control
Date of Injury
Time of Injury
Other
Skip to
Story where injury occurred, if
3
Undetermined
Outside, but not in area
U Block
Below grade
M5
5U
Return
to fire after control
different from M3
Undetermined
Ethnicity
General Location at Time of Injury
M
2
U
Undetermined
E2 1 6 Hispanic
Sleeping
Specific
location
at
time
of
injury
or Latino
Month
Day
Year
Month
Day
Year
Hour
Minute
7
Unable to act
Skip to
1
Non Hispanic or Latino
0
In area of fire origin
Section N
M5 Specific Location at Time of Injury
8
Irrational
act
Primary Apparent Symptom 2
In building,Primary
but notArea
in area
Disposition
of
Body
Injured
ONLY if casualty NOT in area of origin
0N Other
O
P Complete
Skip to
3
Outside, but not in area
Block M5
Human
Factors
Factors
Contributing
U 01Undetermined
None
None
I Cause of Injury
J
K to Injury
Smoke only, asphyxiation
U
Undetermined
Transported to emergency care facility
to Injury
Specific location at time of injury
11
BurnsContributing
and smoke inhalation
1
Exposed to fire products including flame
1
Head
Enter up to three contributing factors
12
Burns only
heat, smoke, and gas
2
Neck and shoulder
First Name
Black, African
American
Activity
When
Injured
MI
Last Name
M21
Block E contains six boxes. Mark one box to record the race of the casualty, if known.
Block E allows you to identify the ethnicity of the casualty. Ethnicity is an ethnic classification or
affiliation. Currently, Hispanic is the only U.S. Census Bureau classification. Hispanic is not considered a race, because a person can be black and Hispanic, white and Hispanic, etc.
Section F: Affiliation
Section F is used to mark the casualtys affiliation - civilian, EMS (not fire department), police, or other.
4-5
MM
Gender
1
Male
Injured Person
First Name
MI
E1
Month
Year
E2
Casualty Number
Suffix
Affiliation
1
2
3
0
Severity
Civilian
EMS, not fire department
Police
Other
Other, multiracial
Undetermined
0
U
Day
Casualty
Number
White
Black, African American
Am. Indian, Alaska Native
Asian
Native Hawaiian, Other
Pacific Islander
OR
Date of Birth
Female
Last Name
Race
1
2
3
4
5
Date of Injury
Time of Injury
Ethnicity
1
0
Hispanic or Latino
Non Hispanic or Latino
Month
Day
Year
Hour
Moderate
Severe
Life threatening
Death
Undetermined
2
3
4
5
U
Minute
Factors
Factors Contributing
None
NFIRS4
None
J Human
K appropriate
Record the month, day, year,
and time
of theDelete
injury
in the
spaces. Time
- hours and minContributing to Injury
Civilian Fire to Injury
Exposed to fire
products
including
flame on theExposure
Incident Number
Station
utes
is
entered
based
24-hour
clock
where
midnight
is
0000.
Casualty
Change
Enter up to three contributing factors
heat, smoke, and gas
DD
YYYY
Cause of
Injury
ident1
Date
Exposed to toxic fumes other than smoke Check all applicable boxes
2
3
Jumped in escape attempt
Casualty
Gender
1
Asleep
C NumberContributing factor (1)
4
Fell, slipped, or tripped
1
Male 2
Female
Unconscious
5
Caught or trapped
3
Possibly impaired by alcohol
6
Structural collapse
Contributing factor (2)
4
Possibly Suffix
impaired by other
drug
Casualty
Number
MI
Last
7
Struck
byName
or contact with object
MM
DD
YYYY
5
Possibly mentally disabled
Overexertion or strain
8
D
A disabled
6
Physically
Multiple causes
E1 9 Race
Incident Number
Incident Datefactor (3)
FDID
Station
Exposure
State
Affiliation
Contributing
7
Physically
restrained
C
Severity
Other
1 0 White
F
H
8
Unattended person
1
Civilian
Undetermined
U
2
Black, African American
2
EMS, not fire department
3
Am. Indian, Alaska Native
Gender
Injured Person
Minor
1
3
Police
4
Asian
Location at Time of B
Incident
Activity
When
Injured
Story
at
Start
of
Incident
1
Male 2
Female
Moderate
2
M3
0 M1 Other
5 L Native Hawaiian, Other
1
In area of origin and not involved
Severe Complete ONLY if injury occurred INSIDE
3
Pacific Islander
2
Not in area of origin
and
not
involved
Midnight is 0000.
Life threatening
4
Story at start of incident
Below grade
First Name
MI
Last Name
Suffix
area of origin,
but involved
Escaping
multiracial
G Date and3 TimeNotof inInjury
0 1 Other,
Death
4
In
area
of
origin
and involved 5
U 2 Undetermined
Rescue attempt
Date of Injury
Time of Injury
0
Other location
Undetermined
U
Injury Occurred
3 Ethnicity
Fire control
M4 Story
E1WhereRace
U
Undetermined
Affiliation
E24 1 Return
Age
or
Date
of
Birth
to fire before control
1
White
D
F
Hispanic or Latino
H
Story
where
injury
occurred,
if
Month
Day
Year
Hour
Minute
Below
grade
5
1
Civilian
Return to fire after control
different from
General Location at Time of Injury
2 M3 Black, African American
Non Hispanic or Latino
0
M
2
6
2
EMS, not fire department
Sleeping
3
Am. Indian, Alaska Native
Months (for infants)
1
7
3
Police
Unable to act
Skip to
4
Asian
1
In area of fire originAge
Specific
Location
at
Time
of
Injury
Section N
2
8
Factors Contributing M5
0
Other
Irrational J
act Human Factors2
None
Native Hawaiian, Other
5
None
In building, butKnot in area
Complete ONLY if casualty NOT in area of origin
3
0
Contributing to3Injury
to Injury
Other
Pacific Islander
Skip to
Midnight
is
0000.
OR
Outside, but not in area
ncluding
flame
Block M5
Date and Time of Injury
4
U
Undetermined
Enter up to three contributing factors
Other,
multiracial
G
0
U
Undetermined
5
Specific
at time of injury
U location
Date of Birth
Undetermined
Date of Injury
Time of Injury
her than smoke Check all applicable boxes
U
Ethnicity
t
Contributing factor (1)
E
2
1
Asleep
Primary Apparent
Symptom
Disposition
1
Hispanic or Latino
Month of Body
Day Injured
Year
Month
Day
Year
Hour
Minute
N
O Primary Area
P
2
Unconscious
Non Hispanic or Latino
0
01
Smoke
asphyxiation
3 only,
Possibly
impaired by alcohol
Transported to emergency care facility
Contributing factor (2)
Burns
smoke inhalation
4 andPossibly
impaired by other1drug Head
object 11
Cause of Injury
Factors
Contrib
12
Burns
None
5 only
Possibly mentally disabled2
Neck and
I shoulder
J Human
K Factors
Local option
Contributing to Injury
to Injury
21
Cut,6laceration
Physically disabled
Remarks
3
Thorax1
Exposed to fire products
including flame
Contributing factor (3)
33
Strain
7 or sprain
Physically restrained
Enter up to three contributing fac
4
Abdomen
heat, smoke, and gas
96
Shock
8
Unattended person
5
Spine 2
Exposed to toxic fumes other than smoke Check all applicable boxes
98
Pain only
6
Upper 3
extremities
Jumped in escape attempt
Contributing factor (1)
1
Asleep
7
Lower
extremities
Look up a code only if the symptom is NOT found above
4
Fell,
Location at Time of Incident
Story
at
Start
of slipped,
Incident or tripped
2
Unconscious
M1 1 In area of origin and not involved
8M3 Internal5
Caught
or
trapped
Complete ONLY if injury occurred INSIDE
3
Possibly impaired by alcohol
9
Multiple
parts collapse
2
Not in area of origin and not involved
6 body
Structural
Primary apparent symptom
Revision 01/01/04
4 NFIRS4
Possibly
impaired by other drug Contributing factor (2)
Story
at start of incident
3
Below
gradeobject
Not in area of origin, but involved
7
Struck by or contact
with
5
Possibly mentally disabled
4
In area of origin and involved
8
Overexertion or strain
0
Other location
6
Physically disabled
Injury Occurred
9
Multiple
causes
M4 Story Where
U
Undetermined
Contributing factor (3)
7
Physically restrained
ol
0
Other
Story where injury occurred, if
8
Unattended person
Below grade
Undetermined
different from M3U
General
Location
at
Time
of
Injury
M2
Section H: Severity
Enter the severity of the injury in Section H. Check one of the five boxes shown: minor, moderate,
severe, life threatening, and death. Severity is a required field.
1
2
3
U
om
iation
halation
above
Skip to
at Time of Incident
Specific
Time
of InjuryYou must
Activity
Injured
Story at Start of Incide
Section N
M5 the
M1 Location
Mark one box to
record
main
causeatWhen
of
injury.
choose
from the eleven possibiliL Location
M3 Complete
1
In area of origin and not involved
ONLY if injury occurred INS
Complete ONLY if casualty NOT in area of origin
Skip to
2
Not in area of origin and not involved
ties provided. Block
M
Story at start of incident
3
Not in area of origin, but involved
1
O
1
2
3
4
5
6
7
8
9
Head
Neck and shoulder
Thorax
Abdomen
Spine
Upper extremities
Lower extremities
Internal
Multiple body parts
Escaping
4
0
U
Specific location
time of injuryattempt
2 atRescue
3
Fire control
4
Return to fire before control
Disposition
P
5
Return to fire after control
6
Sleeping
Transported to emergency care facility
7
Unable to act
8
Irrational act
Local option
Other
Remarks 0
U
Undetermined
M4
M2
1
2
3
U
Skip to
Section N
M5
Specific Location at T
Skip to
Block M5
4-6
N
01
11
12
Disposition
Transported to emerg
1
2
Head
Neck and shoulder
D
Months (for infants)
Age
1
2
3
4
5
White
Black, African American
Am. Indian, Alaska Native
Asian
Native Hawaiian, Other
Pacific Islander
0
U
Other, multiracial
Undetermined
OR
Date of Birth
1
2
3
0
Civilian
EMS, not fire department
Police
Other
Midnight is 0000.
Time of Injury
Day
1
2
3
4
5
U
Minor
Moderate
Severe
Life threatening
Death
Undetermined
Month
1
0
Year
Hispanic or Latino
Non Hispanic or Latino
Month
Day
Year
Hour
Minute
Factors
Contributing
None
None
J Human
K Factors
YYYY
NFIRS4
Contributing to
Injury
to Injury
Delete
Civilian Fire
Exposed to fire products including flame
Enter up to three contributing factors
Incident Date
Station
Exposure
te
Casualty
heat, smoke,
and gas Incident Number
Change
Exposed to toxic fumes other than smoke Check all applicable boxes
2
3
Jumped in escape attempt
Contributing factor (1)
1
Asleep
Casualty
Fell, slipped, or tripped Gender
4
2
Unconscious C
Number
1
5
Caught or trapped
Male 2
Female
3
Possibly impaired by alcohol
Structural collapse
6
4
Possibly impaired by other drug Contributing factor (2)
7MI
Struck
by
or
contact
with
object
Number
Last Name
Suffix
5
Possibly
mentallyCasualty
disabled
Overexertion or strain
8
6
Physically disabled
Multiple causes
9
Race
Contributing factor (3)
7
Physically restrained
E1
Other
0
Affiliation
Severity
rth
8
UnattendedHperson
1
White
MM
DD
YYYY
U
Undetermined F
1
Civilian
A
2
Black, African American
2
EMS,
not
fire
department
3
Am. Indian, Alaska Native
Incident Number
Incident Date
FDID
Station
Exposure
State
ants)
Location at Time of Incident
Minor
1
Police
Activity When Injured 3
4
AsianL
M
1
M
3 Story at Start of Incident
1
I
n
area
of
origin
and
not
involved
Moderate
2
0
Other
Complete ONLY if injury occurred INSIDE
Native Hawaiian, Other
5
2
Not in area of origin and3not involved
Severe
Pacific Islander
Midnight
is 0000. but
Gender
Story at start of incident
Injured
Person
3
Below grade
Not
in
area
of
origin,
involved
1
Escaping
Life threatening
4
B
Other,
G Date and Time 4of Injury
0
In area of origin and involved
1
2 multiracial
Male 2
Female
Rescue attempt
Death
5
U
0
Undetermined
Date of Injury
Time
of Injury
Other
location
Story Where Injury Occurred
3
Fire control
Undetermined
M
4
U
U
Undetermined
Ethnicity
4
Return to fire before control
First Name
MI occurred,
Last Name
Suffix
E2 1 Hispanic
Story where injury
if
Below grade
5
or Latino
Return
to fire after
control
Month
Day
Year General Location
Hour
Minute
different from M3
at Time of Injury
M2
6 Hispanic
Non
or Latino
0
Sleeping
Race
E1
7
Unable to act
Skip to
Affiliation
Age or Date of Birth
1
In area of fire
origin
Specific
Location at Time F
of Injury
Section N
1
White
D
M5
8
Irrational act
2
1
Civilian
In
building,
but
not
in
area
Human
Factors
Factors
Contributing
None
2
Black,
African
American
None Complete ONLY if casualty NOT in area of origin
J Contributing to Injury 3 Outside,Kbut not
0
Other
Skip to
2
EMS, not fire department
in area
to Injury
3
Am. Indian, Alaska Native
Block M5
U
Undetermined
roducts including flame
Months (for infants)
3
Police
U
Undetermined
4
Asian
Enter up to three contributing factors
Age
Specific location at time of injury
gas
0
Other
Native Hawaiian, Other
5
fumes other than smoke Check all applicable boxes
Pacific Islander
Midnight is 00
OR
e attempt
Primary Apparent Symptom
Date and Time of Injury
Contributing
factorArea
(1)
Disposition
Primary
of Body Injured P0
Other, multiracial
G
1
Asleep
N
O
ripped
U
Date of Birth
Undetermined
Date of Injury
Time of Injury
2
Unconscious
d
01
Smoke only, asphyxiation
Transported
to emergency care facility
3
Possibly impaired by alcohol
Ethnicity
se
11
Burns and smoke inhalation
E2 1 Hispanic or Latino
Head
factor (2)
4
Possibly impaired by other drug 1Contributing
act with object
Month
Day
Year
Month
Day
Year
Hour
Minute
12
Burns only
2
Neck and
shoulder
5
Possibly
mentally
disabled
Non Hispanic
Latino
0
train
Localor
option
21
Cut, laceration
Remarks
3
Thorax
6
Physically disabled
33
Strain or sprain
4Contributing
Abdomen
factor (3)
7
Physically restrained
96
Shock
5
Spine
Factors
Cause of Injury
None
8
Unattended person
I
J Human
K Factors
98
Pain only
6
Upper extremities
Contributing to Injury
to Injury
Exposed
to fire products including flame
1 Lower
7
extremities
Look up a code only if the symptom is NOT found above
Enter up to three con
heat, smoke, and gas
at Time of Incident
8
Internal
ured
Story
at
Start of Incident
M1 Location
M3 Complete
Exposed
toxic fumes other than smoke Check all applicable boxes
2ONLY
1
In area of origin and not involved
9
Multiple
bodytoINSIDE
parts
if injury occurred
apparent symptom
3
Jumped in escape attempt
2PrimaryNot
in area of origin and not involved
NFIRS4 Revision 01/01/04
Contributing factor (1)
1
Asleep
Story at start of
3
Below grade
Not in area of origin, but involved
Fell, slipped, or tripped
4 incident
2
Unconscious
4
In area of origin and involved
5
Caught or trapped
3
Possibly impaired by alcohol
0
Other location
Injury Occurred
Structural
collapse
M4 Story6Where
U
Undetermined
4
Possibly impaired by other drug Contributing factor (2)
7
Struck by or contact with object
ore control
Story where injury occurred, if
5
Possibly mentally disabled
Below
grade
Overexertion or strain
r control
different from 8
M3
6
Physically disabled
M2 General Location at Time of Injury
9
Multiple causes
Contributing factor (3)
7
Physically restrained
0
Other
Skip to
1
In area of fire origin
Location at Time of Injury
8
Unattended person
Section N
M
5 Specific
Undetermined
U
2
In building, but not in area
Complete ONLY if casualty NOT in area of origin
Skip to
3
Outside, but not in area
Block M5
U
Undetermined
M1 Location at Time of Incident
L Activity When Injured
M3 Story at Start o
MM
DD
Cause of Injury
You may mark as many of the items shown in Section J as you think apply to the casualty. If no human
factors contributed to the injury, check the box marked None.
If there are factors other than human ones that contributed to the injury, record them in Section K.
If there were no other factors, check the box marked None.
Codes found in the NFIRS Complete Reference Guide (CRG) can be used to identify up to three factors.
nt Symptom
y, asphyxiation
smoke inhalation
ion
rain
O
1
2
3
4
5
6
7
8
9
Head
Neck and shoulder
Thorax
Abdomen
Spine
Upper extremities
Lower extremities
Internal
Multiple body parts
1
Escaping
Disposition
2
Rescue attempt
3
Fire control
Transported
to emergency care facility
4
Return to fire before control
5
Return to fire after control
M2
Sleeping
Local option
Remarks 6
7
Unable to act
1
8
Irrational act
2
0
Other
3
U
Undetermined
U
1
2
3
4
0
U
M4
Skip to
Section N
Story Where In
M5
Specific Locat
Skip to
Block M5
NFIRS4
01
11
12
21
33
96
98
Revision 01/01/04
4-7
Disposition
Transported to
1
2
3
4
5
Head
Neck and shoulder
Thorax
Abdomen
Spine
Remarks
Lo
First Name
MI
E1
Casualty Number
Suffix
Race
Affiliation
F
1
NFIRS 5.0 Self-Study Program
2
1
2
3
4
5
Age
Last Name
White
Black, African American
Am. Indian, Alaska Native
Asian
Native Hawaiian, Other
Pacific Islander
3
0
Civilian
EMS, not fire department
Police
Other
Severity
Minor
Moderate
Severe
Life threatening
Death
Undetermined
1
2
3
4
5
U
Ethnicity
2
Public Month
education
programs
areEdesigned
to orprevent
injuries.
However,
they Hour
also Minute
teach people how to
1
Hispanic
Latino
Day
Year
Month
Day
Year
Non Hispanic or Latino
0
react in the safest manner possible during an emergency. Recording information about the activity
associated Cause
withofanInjury
injury can help determine the
focus of a new public
education
program, or help
Human Factors
Factors Contributing
None
None
I
J
K
determine
if an existing public education program
is having
the desired result.to Injury
Contributing
to Injury
1
Exposed to fire products including flame
MM
State
DD
Incident Date
2
3
4
5
6
7
8
YYYY
9
0
U
(for infants)
E1
1
2
3
4
5
E2
M1
2
Male
M3
0
U
ear
on
of Birth
Use Section M to record information that identifies when and where the injury took place.
1
0
Hispanic or Latino
01
J21
ry
Monthonly,
Dayasphyxiation
Year
Smoke
Hour
Minute
Transported
to emergency
carefire
facility
Non Hispanic
Latino
1 Burns
Use
Block
to mark
one box
that describes
the location of the casualty
at the time
that the
11orM
and smoke
inhalation
1
Head
12
Burns
only
started.
2
Neck and shoulder
Local option
Cut,Factors
laceration
Human
None
Contributing
3Factors
Thorax
None Remarks
33 Contributing
Strain or sprain
Injury
4to general
Abdomen
Mark
boxestoinInjury
M2 to indicate the
location of the casualty at the time of the injury.
re products including
flame one96of the
Shock
5 to threeSpine
Enter up
contributing factors
and gas
98
Pain
only
Leave this block blank and skip to Section 6N if Upper
the location
is undetermined.
extremities
oxic fumes other than smoke
scape attempt
or tripped
pped
llapse
contact with object
or strain
ses
n Injured
Lower extremities
Unconscious
3
Possibly impaired by alcohol
If you mark
Outside,
but not in area, skip to M5.
4
Possibly impaired by other drug Contributing factor (2)
5
NFIRS4
Revision 01/01/04
3 only if the injury occurred inside the building but not in the area of origin.
You will6 complete
Mdisabled
Physically
(3)
7
Physically
restrained
Enter the8 story
where the casualty wasContributing
at thefactor
start
of the incident.
Unattended person
M1
mpt
before control
after control
Contributing
factorInternal
(1)
8 skip
1
Asleep
If you mark
the
box In area of fire origin,
the rest of the section and continue on to Section N.
M3
M4
Below grade
parent Symptom
only, asphyxiation
and smoke inhalation
only
ceration
or sprain
Undetermined
Block M5
Disposition
4-8
Head
Neck and shoulder
Thorax
Abdomen
Remarks
Local option
OR
17
Asleep
Contributing factor (3)
or tripped
4
Physically restrained
Other, multiracial
G Date and Time of Injury
0
28
Unconscious
pped
5
Unattended
person
U
Date of Birth
Undetermined
d
Date of Injury
Time of Injury
3
Possibly
impaired
by
alcohol
lapse
U
Contributing factor (2)
Ethnicity
4
Possibly
impaired
by
other
drug
ontact with object
E
2
5at Time
Possibly
mentally disabled Month StoryDayat StartYear
of Incident
1
Hispanic or Latino
Month
Day
Year
Hour
Minute
Injured
of Incident
or
strain
M1 Location
M3 Complete
6 of origin
Physically
1
In area
and notdisabled
involved
Non Hispanic or Latino
0
NFIRS
ONLY5.0
if injurySelf-Study
occurred INSIDEProgram
es
2
Not7in areaPhysically
of origin and
not involved
Contributing factor (3)
restrained
Story at start of incident
3
Below grade
Not8in areaUnattended
of origin, but person
involved
d
4
Factors
Contr
Cause of Injury
In area of origin and involved
None
pt
I
J Human
K Factors
0
Other location
Contributing to Injury
to Injury
Story Where Injury Occurred
M
4
1
Exposed to fire products including flame
U
Undetermined
Injuredcontrol M1 Location at Time of Incident
Story at Start of Incident
Enter up to three contributing
before
MStory
3 where
heat,
smoke,
gas
injury
occurred, and
if
1
In area of origin and not involved
MM
DD
YYYY ONLY if injury occurred INSIDE
NFIRS4
Below grade
Complete
after control
different
from M3
at Time of Injury
Delete
Exposed
to
toxic
fumes
other
than
smoke
2
A NotLocation
Check
all
applicable
boxes
M2 2General
in area of origin and not involved
Civilian Fire
start of incident
3Story atJumped
in Station
escape attempt
3
Below grade
Not
but involved
Incident Number
Incident Date
FDIDin area of origin,
State
Contributing factor (1)
Casualty
Change
1ExposureAsleep
Skip to
4
1
In
area
of
origin
and
involved
4
Fell,
slipped,
or
tripped
In area of fire origin
pt
Section N
M
5 Specific Location at Time of Injury
2
Unconscious
0
Other
location
2
Caught
or trapped
Story
Where
Injury
Occurred
In building, but not in area
ONLY if casualty
NOT
in area of origin
M56 4 Complete
3
Possibly impaired by alcohol
U5
Undetermined
Skip to
3
Structural collapse
Outside,
but not
in area
Casualty
Gender
Block M5
Injured
Person
4
Possibly impaired
other drug Contributing factor (2)
dbefore control
Story where injury occurred, if
B
C byNumber
7
Struck
by
or
contact
with
object
Below
grade
U
Undetermined
after control
different from M3
General
Location
at
Time
of
Injury
1
2
Male
Female
5
Possibly mentally disabled
Specific location at time of injury
M2
Overexertion or strain
8
6
Physically disabled
9
Multiple causes
Skip to
Contributing factor (3)
7
Physically
restrained
In First
area
of fire origin
Specific
Location at Time of Injury
arent Symptom 1
Casualty Number
Name
Name
Suffix
Section N
0MI5 Last
Other
Disposition
M
Primary
Area
of
Body
Injured
O but not in area
PU Complete
2
8
Unattended person
In building,
ONLY if casualty NOT in area of origin
Undetermined
Skip to
3
Outside, but not in area
only, asphyxiation
Block M5
Race Transported to emergency care facility
E1
Affiliation
U
Undetermined
nd smoke inhalation
Age
or
Date
of
Birth
1
Head
1
White
D
F
location
at timeInjured
of injury
at Time of Incident
H Severity M3 Story at Start of Incid
Activity
When
nly
M1 Location
L Specific
1
Civilian
2
Neck and shoulder 2
Black, African American
1
In area of origin and not involved
Complete ONLY if injury occurred I
Local option 2
eration
EMS, not
department
3
Thorax
2 fire Not
in area of origin and not involved
3
Am.Remarks
Indian, Alaska Native
arent
Symptom
Disposition
Months
(for infants)
Primary
Area
of
Body
Injured
r sprain
Minor
1
Story
at start of incident
3
Police
3
Not
in
area
of
origin,
but
involved
1
O
P
4
Abdomen
Escaping
4
Asian
Age
Moderate
2
In area of origin and involved
0
Other 4
2 Hawaiian,
5
Spine
Rescue
attempt
Native
Other
5
only,
asphyxiation
0
ly
Severe
Transported
3
Pacific
3 Islander
6
Upper extremities
Fire control to emergency care facility Other location
Midnight is 0000.
M4 Story Where Injury O
nd smoke inhalation
OR
Undetermined
17
Head
Date and Time Uof Injury
Life threatening
4
4
Lower
extremities
Return
to
fire
before
control
mptom
is
NOT
found
above
Other,
multiracial
G
0
1
nly
Story where injury occurred, if
2
Neck and shoulder U
Death
5
5
Return to fireLocal
after
control
Date of8Birth Internal
Undetermined
different from M3
Date
of Injury
Time of Injury
General Location
at Time of Injury
option
eration
Remarks
39
Thorax
M
2
Undetermined
U
6
Multiple body parts
Sleeping
Ethnicity
r sprain
4
Abdomen
NFIRS4 Revision 01/01/04
E2 1 Hispanic
7
Unable to act
Skip to
1Year In area ofHour
or Latino
fire origin
Month 5
DaySpine Year
Month
Day
Minute
Section N
M5 Specific Location at
8
Irrational act
y
2
Non
Hispanic
or
Latino
0
In
building,
but
not
in
area
6
Upper extremities
Complete ONLY if casualty NOT i
0
Other
Skip to
3
Outside, but not in area
7
Lower extremities
mptom is NOT found above
Block M5
U
Undetermined
U
Undetermined
8
Internal
Factors
Contributing
of Injury
None
None Specific location at time of injury
I 9CauseMultiple
J Human
K Factors
body parts
Contributing to Injury
to Injury
NFIRS4
Revision
01/01/04
Exposed to fire products including flame
1
Primary Apparent Symptom
Enter up to three contributing factors
heat, smoke, and gas
N
O Primary Area of Body Injured P Disposition
Exposed to toxic fumes other than smoke Check all applicable boxes
2
01
Smoke only, asphyxiation
Transported to emer
3
Jumped in escape attempt
Contributing factor (1)
11 1 Burns
and smoke inhalation
Asleep
1
Head
Fell, slipped, or tripped
4
12 2 Burns
only
Unconscious
2
Neck and shoulder
5
Caught or trapped
Local option
21 3 Cut,Possibly
laceration
impaired by alcohol
Remarks
3
Thorax
Structural collapse
6
factor (2)
33 4 Strain
or sprain
Possibly
impaired by other drug 4Contributing
Abdomen
7
Struck by or contact with object
96 5 Shock
Possibly mentally disabled
5
Spine
Overexertion or strain
8
98 6 Pain
only
Physically
disabled
6
Upper extremities
Multiple causes
9
factor (3)
7
Physically restrained
7Contributing
Lower
extremities
Look up a code only if the symptom is NOT found above
Other
0
8
Unattended person
8
Internal
Undetermined
U
9
Multiple body parts
If the injury happened in the building but did not occur in the area of fire origin, complete Block
M.
Enter the description and code found in the CRG which best explains the location.
The code set table used for this data element is the same set that is used for Area of Fire Origin - D
in the Fire Module. Please see the codes listed for the data element found in the CRG.
M1
M3
M4
Use
Section
N to record the symptom of the most apparent serious
injury. Section N lists several
of
Story at start of incident
Below grade
1
Escaping
the2 most
common
Rescue
attempt symptoms along with specific identifying codes. Check the appropriate box.
3
Fire control
Return to fire
before control
If 45the primary
symptom
is not on the list, look for a suitable code Story
in where
theinjury
CRG.
the appropriate
occurred,Enter
if
Below grade
Return to fire after control
different from M
General Location at Time of Injury
M
2
code
on
the
line
provided.
6
Sleeping
3
7
8
0
U
Unable to act
Irrational act
Other
Undetermined
1
2
3
U
Skip to
Section N
M5
Skip to
Block M5
N
01
11
12
21
33
96
98
Disposition
Transported to emergency care facility
1
2
3
4
5
6
7
8
9
Head
Neck and shoulder
Thorax
Abdomen
Spine
Upper extremities
Lower extremities
Internal
Multiple body parts
Remarks
Local option
NFIRS4
4-9
Revision 01/01/04
4
5
6
7
8
Injured
M1
M2
1
2
3
U
arent Symptom
only, asphyxiation
nd smoke inhalation
nly
eration
r sprain
1
2
3
4
0
U
M3
Not in area of
and not involved
Use Section
Oorigin
to identify
the areaStory
ofatthe
body that sustainedBelowthe
most serious injury.
start of incident
grade
Not in area of origin, but involved
pt
before control
after control
MakeOther
onelocation
choice from the nine M
listed
in the section. It should be the same part of the body affected
4 Story Where Injury Occurred
Undetermined
by the Primary Apparent SymptomStoryinwhereSection
injury occurred,N.
if
Below grade
General Location at Time of Injury
In area of fire origin
In building, but not in area
Outside, but not in area
Undetermined
Skip to
Section N
Skip to
Block M5
different from M3
M5
Section P: Disposition
Complete ONLY if casualty NOT in area of origin
Disposition
Transported to emergency care facility
1
2
3
4
5
6
7
8
9
Head
Neck and shoulder
Thorax
Abdomen
Spine
Upper extremities
Lower extremities
Internal
Multiple body parts
Remarks
Local option
Mark the box in this section if the casualty was transported to an emergency care facility.
If you are using paper forms instead of the software program, use the space on the forms to supply
additional remarks.
NFIRS4
Revision 01/01/04
SUMMARY
The Civilian Fire Casualty Module captures data regarding any civilian (nonfire service) casualty
associated with fire-related incidents. If civilian injuries or deaths are recorded in H1 of the Basic
Module, then you are required to complete the Civilian Fire Casualty Module.
A civilian casualty can be a private citizen, emergency medical responder (nonfire department), or
police officer who dies or is physically injured as the result of a fire-related incident. This description
is not meant to exclude other people who fall into this category. For instance, any number of public
and emergency services personnel may be on the scene of an emergency, such as public works personnel, State highway personnel, and other Federal, State, or local employees/officials.
4-10
4-11
4-12
4-13
DD
Delete
FDID
State
Incident Date
Station
Gender
1
Male
First Name
MI
E1
Date of Birth
Month
Day
Year
Race
0
U
Other, multiracial
Undetermined
Affiliation
1
2
3
0
E2
1
0
Date of Injury
Hispanic or Latino
Non Hispanic or Latino
Cause of Injury
M1
Midnight is 0000.
Time of Injury
Escaping
Rescue attempt
Fire control
Return to fire before control
Return to fire after control
Sleeping
Unable to act
Irrational act
Other
Undetermined
Month
Day
Year
Human Factors
Contributing to Injury
Hour
None
Severity
Minor
Moderate
Severe
Life threatening
Death
Undetermined
1
2
3
4
5
U
Minute
Factors Contributing
to Injury
None
1
2
3
4
5
6
7
8
Asleep
Unconscious
Possibly impaired by alcohol
Possibly impaired by other drug
Possibly mentally disabled
Physically disabled
Physically restrained
Unattended person
Casualty Number
Civilian
EMS, not fire department
Police
Other
Casualty
Number
Female
Ethnicity
1
2
3
4
5
6
7
8
0
U
Change
Suffix
White
Black, African American
Am. Indian, Alaska Native
Asian
Native Hawaiian, Other
Pacific Islander
Exposure
Last Name
1
2
3
4
5
OR
Incident Number
Injured Person
2
3
4
5
6
7
8
9
0
U
NFIRS4
Civilian Fire
Casualty
YYYY
M2
1
2
3
U
Skip to
Section N
M3
M4
Below grade
M5
Below grade
Skip to
Block M5
N
01
11
12
21
33
96
98
Disposition
Transported to emergency care facility
1
2
3
4
5
6
7
8
9
Head
Neck and shoulder
Thorax
Abdomen
Spine
Upper extremities
Lower extremities
Internal
Multiple body parts
Remarks
Local option
NFIRS4
4-14
Revision 01/01/04
4-15
4-16
Delete
Incident Date
State
Location Type
Station
Incident Number
Exposure
NFIRS1
Number/Milepost
Prefix
Basic
No Activity
Check this box to indicate that the address for this incident is provided on the Wildland Fire
Module in Section B, Alternative Location Specification." Use only for wildland fires.
Street address
Intersection
In front of
Rear of
Adjacent to
Directions
US National Grid
Census Tract
Street or Highway
Street Type
Suffix
Apt./Suite/Room
City
State
ZIP Code
Incident Type
E1
Incident Type
YYYY
Change
FDID
DD
None
Midnight is 0000
Month
Check boxes if
dates are the
same as Alarm
Date.
Day
Year
Hour
E2
Min
Shift or
Platoon
Alarm
Alarms
District
1
2
3
4
5
Their FDID
Last Unit
Cleared
G1
Resources
G2
Apparatus
Personnel
Suppression
Additional Action Taken (2)
H1
Casualties
None
Deaths Injuries
Fire
Service
Civilian
H2
1
2
U
Detector
Required for confined fires.
H3
1
2
3
4
5
6
7
8
0
Special
Study Value
LOSSES:
Property
Contents
None
EMS
Other
Additional Action Taken (3)
Special
Study ID#
Fire2
Structure Fire3
Local Option
Controlled
Actions Taken
Completed Modules
Special Studies
Their
State
E3
Arrival
Property
Contents
None
Mixed Use
Property
10
20
33
40
51
53
58
59
60
63
65
00
Not mixed
Assembly use
Education use
Medical use
Residential use
Row of stores
Enclosed mall
Business & residential
Office use
Industrial use
Military use
Farm use
Other mixed use
Property Use
None
Structures
Church, place of worship
131
Restaurant or cafeteria
161
Bar/tavern or nightclub
162
Elementary school, kindergarten
213
High school, junior high
215
College, adult education
241
Nursing home
311
Hospital
331
341
342
361
419
429
439
449
459
464
519
539
571
579
599
615
629
700
819
882
891
Outside
Playground or park
124
Crops or orchard
655
Forest (timberland)
669
Outdoor storage area
807
Dump or sanitary landfill
919
Open land or field
931
936
938
946
951
960
961
962
Vacant lot
Graded/cared for plot of land
Lake, river, stream
Railroad right-of-way
Other street
Highway/divided highway
Residential street/driveway
981
984
Construction site
Industrial plant yard
4-17
Property Use
Code
Property Use Description
NFIRS1 Revision 01/01/05
K1
Local Option
First Name
Number
Prefix
State
Area Code
MI
Phone Number
Last Name
Suffix
Street or Highway
Street Type
Apt./Suite/Room
Suffix
City
ZIP Code
More people involved? Check this box and attach Supplemental Forms (NFIRS1S) as necessary.
Owner
K2
Local Option
First Name
Number
MI
Prefix
Phone Number
Last Name
Suffix
Street or Highway
Street Type
Apt./Suite/Room
State
Area Code
Suffix
City
ZIP Code
Remarks:
Local Option
ITEMS WITH A
More remarks? Check this box and attach Supplemental Forms (NFIRS1S) as necessary.
Authorization
Check box if
same as
Officer in
charge.
Officer in charge ID
Signature
Position or rank
Assignment
Month
Day
Year
Signature
Position or rank
Assignment
Month
Day
Year
4-18
MM
FDID
DD
YYYY
Incident Date
State
Station
Property Details
B1
C
Not Residential
Incident Number
On-Site Materials
or Products
Change
Exposure
None
On-Site Materials
Storage Use
1
2
3
4
U
1
2
3
4
U
1
2
3
4
U
B3
None
D
D1
D2
Ignition
E1
Heat source
D3
Item first ignited
Cause of Ignition
Skip to
Section G
E3
Intentional
Unintentional
Failure of equipment or heat source
Act of nature
Cause under investigation
Cause undetermined after investigation
E2
3
4
5
None
6
Estimated age of
person involved
F1
F2
None
Asleep
Possibly impaired by
alcohol or drugs
Unattended person
Possibly mentally disabled
Physically disabled
Multiple persons involved
1
2
Human Factors
Contributing to Ignition
1
2
3
4
5
U
D4
Fire
B2
NFIRS2
Delete
Male
Female
None
Equipment Involved
F3
Brand
Model
Serial #
Equipment Portability
1
Portable
Stationary
Year
H1
None
H2
Local Use
Pre-Fire Plan Available
Some of the information presented in this report may be
based upon reports from other agencies:
Year
State
VIN
Structure fire? Please be sure to complete the Structure Fire form (NFIRS3).
NFIRS2 Revision 01/01/05
4-19
I1
1
2
3
4
5
6
7
8
0
Enclosed building
Portable/mobile structure
Open structure
Air-supported structure
Tent
Open platform (e.g., piers)
Underground structure (work areas)
Connective structure (e.g., fences)
Other type of structure
Fire Origin
J1
I2
Building Status
1
2
3
4
5
6
7
0
U
Under construction
Occupied & operating
Idle, not routinely used
Under major renovation
Vacant and secured
Vacant and unsecured
Being demolished
Other
Undetermined
J3
None Present
Present
Undetermined
Detector Type
1
2
3
4
5
0
U
Smoke
Heat
Combination smoke and heat
Sprinkler, water flow detection
More than one type present
Other
Undetermined
M1
1
2
3
4
5
6
7
0
U
0
U
L4
Detector Operation
Operated
Complete
Block L5
Failed to operate
Complete
Block L6
Undetermined
Wet-pipe sprinkler
Dry-pipe sprinkler
Other sprinkler system
Dry chemical system
Foam system
Halogen-type system
Carbon dioxide (CO2) system
Other special hazard system
Undetermined
Width in feet
K1
Skip to
Section L
M3
K2
Type of material contributing
most to flame spread
L5
Battery only
Hardwire only
Plug-in
Hardwire with battery
Plug-in with battery
Mechanical
Multiple detectors & power
supplies
Other
Undetermined
1
2
3
4
5
6
7
M2
BY
Length in feet
L3
Skip to
Section M
,
Total square feet
Fire Spread
NFIRS3
Structure
Fire
OR
Presence of Detectors
L2
Story of
fire origin
L1
I4
2
3
4
5
Building
Height
Below grade
J2
I3
1
2
3
4
U
L6
Detector Effectiveness
Required if detector operated.
1
2
3
4
5
6
0
U
Operation of Automatic
Extinguishing System
M5
1
2
3
4
0
U
M4
Number of Sprinkler
Heads Operating
1
2
3
4
5
6
7
8
0
U
4-20
Revision 01/01/06
MM
DD
Delete
FDID
State
Incident Date
Incident Number
Station
Gender
1
Male
Injured Person
First Name
MI
E1
Date of Birth
Month
Day
Year
Race
0
U
Other, multiracial
Undetermined
1
0
Cause of Injury
Escaping
Rescue attempt
Fire control
Return to fire before control
Return to fire after control
Sleeping
Unable to act
Irrational act
Other
Undetermined
Affiliation
1
2
3
0
M1
Midnight is 0000.
Time of Injury
Month
Day
Year
Human Factors
Contributing to Injury
Hour
None
Severity
Minor
Moderate
Severe
Life threatening
Death
Undetermined
1
2
3
4
5
U
Minute
Factors Contributing
to Injury
None
1
2
3
4
5
6
7
8
Asleep
Unconscious
Possibly impaired by alcohol
Possibly impaired by other drug
Possibly mentally disabled
Physically disabled
Physically restrained
Unattended person
Casualty Number
Civilian
EMS, not fire department
Police
Other
Date of Injury
Hispanic or Latino
Non Hispanic or Latino
1
2
3
4
5
6
7
8
0
U
Casualty
Number
Female
Ethnicity
E2
Change
Suffix
White
Black, African American
Am. Indian, Alaska Native
Asian
Native Hawaiian, Other
Pacific Islander
Exposure
Last Name
1
2
3
4
5
OR
2
3
4
5
6
7
8
9
0
U
NFIRS4
Civilian Fire
Casualty
YYYY
M2
1
2
3
U
Skip to
Section N
M3
M4
Below grade
M5
Below grade
Skip to
Block M5
N
01
11
12
21
33
96
98
Disposition
Transported to emergency care facility
1
2
3
4
5
6
7
8
9
Head
Neck and shoulder
Thorax
Abdomen
Spine
Upper extremities
Lower extremities
Internal
Multiple body parts
Remarks
Local option
NFIRS4
4-21
Revision 01/01/04