FIRE FATALITY ONLINE SUBMISSION FORM

Completion and submission of this form is NOT a substitute for the completion and submission of the Fire Casualty report that is a part of your NFIRS/LFIRS reporting.

Please follow the instructions very carefully, reading all the questions thoroughly before submitting. If any information is unknown, leave blank and go on to the next block.

Date Reported

Date Reported:

Deceased Victim/Persons Information

First Name:

Middle Name:

Last Name:

Suffix:

Date of Birth:

Gender:

Male
Female

Incident Information

Incident Date:

Incident Time:

Street Address:

City:

State:

Zip Code:

Origin and Cause Information

Point of Origin:

Likely Cause:

Criminal Charge:

Yes
No

Detection /Alarm /Sprinklers Present:

Yes
No

Detection /Alarm /Sprinklers Functional:

Yes
No

Additional Comments:

Reporting Agency Information

Reporting Agency:

Street Address:

City:

State:

Zip:

Agency Phone:

Person Filing Report:

Consent for storing submitted data

Yes, I give permission to store and process my data

FIRE FATALITY ONLINE SUBMISSION FORM

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