IFD Safety Division – Department Vehicle Accident IFD Safety Division - Department Vehicle Accident Incident InformationDate of Incident* MM slash DD slash YYYY Day of the Week*SelectSundayMondayTuesdayWednesdayThursdayFridaySaturdayTime of Accident* : Hours Minutes AM PM Apparatus / Vehicle*SelectEngineLadderSquadTacTankerTSUGrass RigSafety CarEDO CarBoatStaff CarMIRVBattalion ChiefCarApparatus / Car Number* Reserve* Yes No Asset Tag* Asset Tag should be located on the drivers door of any large apparatus. On BC buggies and staff cars it should be on the windshield and inside the drivers door. Along with the gas card pouch.Apparatus Damage Estimate*Shift*SelectA ShiftB ShiftC ShiftWeek DaysIFD Incident Number* Location of Accident* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Status* Emergency Response Returning from Response Parked on Scene Parked Other Non-Emergency Response Not on Response (ie: store, fuel, etc.) Parked on Station Other Emergency Devices in Use* Lights Siren None Law Enforcement CAD # Did Law Enforcement investigate? Yes No Law Enforcement Investigator Name Law Enforcement ID Vehicle Operator InformationOperator Name* Operator Rank*SelectPrivateEngineerLieutenantCaptainBattalion ChiefCivilianOperator Date of Birth* MM slash DD slash YYYY Operator Gender*SelectMaleFemaleDriver's License Number* Operator Battalion*Select1234567AdminOperator Assigned Location*SelectAdmin - HQAdmin - ShopsAdmin - QuartermasterAdmin - Fire PreventionAdmin - ArsonStation 01Station 02Station 03Station 04Station 05Station 06Station 07Station 08Station 09Station 10Station 11Station 12Station 13Station 14Station 15Station 16Station 17Station 18Station 19Station 20Station 21Station 22Station 23Station 24Station 25Station 26Station 27Station 28Station 29Station 30Station 31Station 32Station 33Station 34Station 35Station 36Station 41Station 42Station 43Station 44Station 45Station 46Station 52Station 53Station 54Station 55HiddenOperator Work Assignment Regular Assignment Substitute Roving / Unassigned Other Operator Work Assignment* Regular Assignment Substitute Roving/Unassigned Rideout Other Work Status* Regular Shift Overtime Trade Time Other Operator Narrative*If Operator is a certified Engineer, how long have they held the Engineer Certification? If not an Engineer, type NA.If operator is a Certified Engineer, what is their primary apparatus?Select OneEngineLadderSquadOtherHow many years of experience does the operator have driving an apparatus? Property DamageDamage Done to Property* Motor Vehicle Structure Overhead Door None Other Other Business (if applicable) Owner / Driver Name Owner / Driver Date of Birth MM slash DD slash YYYY Owner / Driver GenderSelectMaleFemaleOwner / Driver Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Owner / Driver PhoneOwner / Driver Driver's License Number Owner / Driver Insurance Company Owner / Driver Policy NumberProperty Damage Estimate*Additional InformationInjury InformationDo you have an additional injury to report in from this same incident?SelectYesNoInjuries Apparatus Operator Other Driver Property Owner / Occupant Apparatus Passenger Other Passenger Supervisor InformationSupervisor Name* Supervisor Rank*SelectPrivateLieutenantCaptainBattalion ChiefChiefSupervisor at Scene?* Yes No Supervisor NarrativeWitness InformationInclude other crew members or witnessesNumber of WitnessesSelect0123Witness #1 Name Witness #1 Rank/TitleSelectPrivateLieutenantCaptainBattalion ChiefChiefCaptainDivision ChiefDeputy ChiefCivilianEngineerWitness #1 NarrativeWitness #2 Name Witness #2 Rank/TitleSelectPrivateLieutenantCaptainBattalion ChiefChiefDivision ChiefDeputy ChiefCaptainCivilianWitness #2 NarrativeWitness #3 Name Witness #3 Rank/TitleSelectPrivateLieutenantCaptainBattalion ChiefChiefDivision ChiefDeputy ChiefCaptainCivilianWitness #3 NarrativeWeather DataTemperature*Precipitation* None Rain Fog Freezing Rain Drizzle Snow Road Surface* Dry Wet Icy Visibility*SelectSunriseDaylightSunsetDarkInvestigator SectionLead Investigator/Safety Chief Name* Lead Investigator Email Address Investigator Rank*SelectCaptainBattalion ChiefChiefDivision ChiefDeputy ChiefInvestigator/Safety Chief Number*SelectNorthCentralSouthOtherLead Investigator Narrative (Be extremely thorough with details)*Requesting Black Box Data*SelectYesNoRequesting Driver History Data*SelectYesNoRequesting Bay Door Maintenance History*SelectYesNoAdditional InformationName of Assigned Shift Commander on Date of Accident Assigned Shift Commander's Email Case Paperwork Drop files here or Select files Max. file size: 5 MB.
