Feh Incident Form - Wood River Fire Department

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WOOD RIVER FIRE DEPARTMENT
FEH INCIDENT FORM
Date of Incident _______________
______ STRUCTURAL FIRE
_____________ DISPATCH TIME
___________ START MILEAGE
______ AUTO ACCIDENT
______ HAZARDOUS MATERIAL INCIDENT
_____________ BACK IN SERVICE TIME
___________ END MILEAGE
______ VEHICLE FIRE
______ EXTRICATION CALL
_____________ INCIDENT NUMBER
___________ MILEAGE
______ WATER RESCUE/RECOVERY
______ GRASS FIRE
LOCATION OF INCIDENT: _______________________________________________________________________________________________
NAME OF INSURED:_____________________________________________________________________________________________________
ADDRESS: ________________________________________ CITY:_________________________ STATE _____________ ZIP _______________
NAME OF INSURANCE COMPANY: _______________________________________________________________________________________
POLICY NUMBER:_________________________________
AGENT: (IF AVAILABLE) ________________________ Tel# _________________
IF OTHERS ARE INVOLVED COMPLETE THE SUPPLEMENTAL INFORMATION FORM
ACTION TAKEN:
_____ INCIDENT COMMAND
______ EXTINGUISH FIRE
_____ LAND HELICOPTER
_____ SCENE SAFETY
______ ASSIST EMS
_____ ASSIST OTHER AGENCIES
_____ SECURE SCENE
______ EXTRICATE PATIENT(S)
_____ WATER RESCUE
_____ SECURE VEHICLE
______ CLEAN UP HAZMAT
_____ TRAFFIC CONTROL
______ CLEAN UP ACCIDENT DEBRIS
__________________________________________________________________________________________
NARRATIVE:
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
RESPONSE VEHICLES
_____ PUMPER
_____/hr
_____ AERIAL LADDER TRUCK
_____/hr
_____ COMMAND VEHICLE ____/hr
_____ PUMPER
_____/hr
_____ GRASS RIG
_____/hr
_____ TANKER
_____/hr
_____ UTILITY TRUCK
_____/hr
_____ TANKER
_____/hr
_____ RESCUE UNIT/WATER RESCUE
_____/hr
_____________________________________________________________________________________________________________________________
EQUIPMENT USED
_____ JAWS OF LIFE
_____ CRIBBING BLOCKS
_______ VENTILATING FAN
_____ POWER SAW
_____ WINCHES
_____ HYDRAULIC JACK/CHISELS
_____ AIR BAGS
______ OTHER _________________________________________
_________________________________________________________________________________________________________
SUPPLIES
_____ SAFETY FLARES
______ CLASS A FOAM
_____ CLASS AFFF FOAM
_____ ABSORBANT PADS
______ # BAGS ABSORBANT
OTHER SUPPLIES_______________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________
DAMAGED EQUIPMENT (Department equipment damaged at the scene)
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
DAMAGED EQUIPMENT CHARGES__________
Mutual Aid for this incident with ____________________ Person completing incident information __________________________________________

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