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About MFD
Our History
Our Stations
ISO Information
Community Outreach
Public Relations Request
Request Smoke Alarms
After A Fire
CPR Course
Careers
Employment
MCESD#10
Public Notices
Our Board
MCESD10 Contact Info
What is an ESD?
Tax Rate Information
Bid and RFP Information
Contact US
Election
Election Website
Order of Election
Notice of Election
More Election Info
Canvass Order – Sales Tax
Request A Smoke Alarm
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Magnolia Fire Incident Investigation Form
Reporting Information
Step
1
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*
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Time
*
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1 AM
2 AM
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5 AM
6 AM
7 AM
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11 AM
12 PM
1 PM
2 PM
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11 PM
Incident Number
Apparatus
Person Completing Report
Last Name
First Name
MI
Rank
Involved Employee
Last Name
First Name
MI
Rank
Incident Type
Incident without Injury
Incident with Injury
Damage to Apparatus or Equipment
Damage to Property
Exposure
Near Miss Event
Did the employee seek medical treatment?
Yes
No
Is it suspected that the employee will have lose time?
Yes
No
Employee Length of Service With Department
Less than 1 Month
1 Month - 6 Months
6 Months - 5 years
More than 5 years
Did the incident occur during training?
Yes
No
Involved Employee's Supervisor
Last Name
First Name
MI
Rank
The employees ASSIGNED Battalion Chief
A. Vulgamott
M. Akers
J. Czichos
D. Farley
A. Paulk
J. Ross
Their normally assigned BC (this may be different than who is working today, it is simply to ensure their BC is kept in the loop)
Location of Incident
House
Commercial Building
Street
Parking Lot
Weather conditions at the time of incident:
Precipitation
Clear
Cloudy
Rain
Ice
Storm
Other
Describe the conditions
Address or Closest Address
Address Line 1
Address Line 2
City
Zip / Postal Code
Part of Body Affected or Injured
Skull
Jaw
Abdomen
Shoulder
Wrist
Knee
Foot
Eye
Neck
Back
Upper Arm
Hand
Finger
Toe
Nose
Spine
Pelvis
Elbow
Finger
Lower Leg
Mouth
Chest
Forearm
Hip
Ankle
Other
Nature of Injury or Illness
Puncture
Laceration
Fracture
Heat/Cold Stress
Bruise, Contusion
Dislocation
Abrasion
Hearing Loss
Skin Disorder
Burn
Respiratory
Chemical Exposure
Amputation
Insect/Animal Bite
Foreign Body
Muscle Sprain
Muscle Strain
Hernia
Cumulative Trauma
Irritation
Infection
Other
Briefly describe events of the incident
List preliminary cause of the incident
Was this incident a structure fire?
Yes
No
Was an after action review conducted
Yes
No
Identify Preventative Actions or Recommendations (check all that apply)
Re-instruction of person(s) involved
Reprimand of person(s) involved
Discipline of person(s) involved
Utilize different method for task
Improve design of equipment
Repair or replace broken equipment
Improve Personal Protective Equipment
Provide better employee supervision
Other (explain)
Explain
Investigating Officer Comments:
*****Warning***** You selected that an injury has occured. Once you submit this report you will be redirected to have the employee sign the Workwell Notice.
Employee Email
*
Investigating Officer Name
Signature
reCaptcha
Date Submitted
Email
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