NJDFS Firefighter Injury / Fatality Notification Form

(SUBMISSION OF THIS FORM IS REQUIRED WITHIN 4 HOURS OF OCCURENCE)

Incident Location Information

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Fire Department / EMS / Hospital Information

Type of Fire Department: *

Firefighter Injury / Fatality Information





NOTE:
If this incident resulted in the Firefighter(s) being ADMITTED into the hospital, or their DEATH you MUST also make the following notifications BY PHONE 24/7:
 
NJDFS 1-877-653-4737 / NJDOL PEOSH 1-800-624-1644
By signing below you are verifying all information above is accurate to the best of your knowledge: *
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By signing below you are verifying all information above is accurate to the best of your knowledge: *
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