Form 1403 - Live Burn Accountability
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2Virginia Department of Fire Programs
Location: ___________________________
Date: _________
School No.: _____________
Live Burn Accountability
Individual Name:
_____________________________
Department: _____________________
Emergency Contact: _____________________________
Allergies:
_____________________
Known Medical Problems: ____________________________________________________________
Note: Remember to keep crews well hydrated during time in staging or rehabilitation
VITAL SIGNS
B/P
RESP.
PULSE
TEMP.
SKIN
TAKEN BY:
Base Line
Post Entry #1
Post Entry #2
Post Entry #3
Post Entry #4
Post Entry #5
Post Entry #6
Post Entry #7
PERSONNEL/TURNOUT GEAR INSPECTION:
Coat: ________________
Pants: _____________
Helmet: ______________
Boots: ________________
Gloves: ______________
Hood: _____________
SCBA: ______________
Pass: ________________
Accountability: ________
Problems with Personnel/Gear: _______________________________________________
TRAINING LEVEL:
The above named individual meets the following training Job Performance Requirements (JPR).
These NFPA 1001 JPR subjects are listed in the appendix of NFPA 1403.
Safety
Fire Behavior
Portable Extinguishers
Personal Protective Equipment
Ladders
Fire Hose, Appliances, and
Overhaul
Water Supply
Ventilation
Forcible Entry
I _______________________________ certify that I have received the above training prior to entering
the Live Fire Training being offered here. I also certify the above information is true.
Signature: _________________________________
____/____/______
(Legible Signature)
(Date)
I _______________________________ certify that _______________________________ has received
the above training prior to entry into the Live Fire Training being offered, I also certify the above
information is true.
Signature of
Dept. Official: _____________________________ Title: _________________ Date: ___/___/___
Signature of Lead Instructor: ________________________________________ Date: ___/___/___
Signature of Safety Officer: _________________________________________ Date: ___/___/___
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