subject_line
New Jersey Division of Fire Safety
Office of the State Fire Marshal - Fire Fatality Report Form
Date of Incident:
*
+
Alarm Time (24Hr):
*
Municipality:
*
Incident Address:
*
Zip Code:
*
Fire Department Name:
*
FDID:
*
Please check this box if property was an illegal Residential Conversion
NFIRS Participant: (Check One)
*
Yes
No
Name
*
Age:
*
Gender:
*
Affiliation:
*
Civilian
Firefighter
Other - Emergency Personnel
Name
Age:
Gender:
Affiliation:
Civilian
Firefighter
Other - Emergency Personnel
Name
Age:
Gender:
Affiliation:
Civilian
Firefighter
Other - Emergency Personnel
Name
Age:
Gender:
Affiliation:
Civilian
Firefighter
Other - Emergency Personnel
Name
Age:
Gender:
Affiliation:
Civilian
Firefighter
Other - Emergency Personnel
Name
Age:
Gender:
Affiliation:
Civilian
Firefighter
Other - Emergency Personnel
Name
Age:
Gender:
Affiliation:
Civilian
Firefighter
Other - Emergency Personnel
Cause of Fire:
*
Room of Origin:
*
Type of Occupancy
*
Detector Present: (Check One)
*
Yes
No
Unknown
Detector Operate: (Check One)
*
Yes
No
Unknown
Reporting Agency:
*
Name: (Person Completing Form)
*
Phone:
*
Remarks:
Please enter e-mail address below; a copy of this form will be sent after you have submitted the report.
*