subject_line
NJDFS Firefighter Injury / Fatality Notification Form
(SUBMISSION OF THIS FORM IS REQUIRED WITHIN 4 HOURS OF OCCURENCE)
Incident Location Information
Date of Incident:
*
+
Time of Incident:
*
AM / PM
*
AM
PM
Location:
*
Street Address:
*
Municipality:
*
Where Injury Occurred (Pick 1)
*
Apparatus
Fire Academy
Home
Scene
Station
Other
If OTHER Please Indicate Location:
Fire Department / EMS / Hospital Information
Fire Department Name:
*
Street Address:
*
Municipality:
*
Type of Fire Department:
*
Career
Combination
Fire District
Municipal
Volunteer
Other
If OTHER Please Indicate:
FDID # (If Known):
NFIRS Participant:
*
Yes
No
Contact Person:
*
Phone Number:
*
Responding EMS Agency (If Applicable):
Hospital Name (If Applicable):
Firefighter Injury / Fatality Information
Firefighter Name:
*
Firefighter Age:
*
Nature of Injury:
*
Hospitalization:
*
Yes
No
Back to Work:
*
Yes
No
Firefighter Name:
Firefighter Age:
Nature of Injury:
Hospitalization:
Yes
No
Back to Work:
Yes
No
Firefighter Name:
Firefighter Age:
Nature of Injury:
Hospitalization:
Yes
No
Back to Work:
Yes
No
Firefighter Name:
Firefighter Age:
Nature of Injury:
Hospitalization:
Yes
No
Back to Work:
Yes
No
Firefighter Name:
Firefighter Age:
Nature of Injury:
Hospitalization:
Yes
No
Back to Work:
Yes
No
Incident Description:
*
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
Phone Notification Also Made:
*
Yes
No
Contact's Email Address:
*
Confirm Email Address:
*
By signing below you are verifying all information above is accurate to the best of your knowledge:
*
clear
ENTER THE EMAIL ADDRESS YOU WOULD LIKE A COPY OF THIS FORM SENT TO:
*