Fire Casualty Report*** Must be sent within 24 hours ***

Fire Casualty Report

*** Must be sent within 24 hours ***

Please Note:

Fire Agencies in Oregon are required to submit this report on all deaths or serious injuries within 24 hours.
For questions about submitting this form contact the Analytics & Intelligence Unit at 503-934-8250, 877-588-8787 (toll free) or OSFM.DATA@osfm.oregon.gov.
A complete NFIRS Fire Report for this victim must also be submitted into the state repository.

Fire Agency Name*

The agency responsible for entering the required NFIRS Fire Report for this victim.

FDID*

County*

Deputy State Fire Marshal Response*

Yes

Deputy State Fire Marshal Name*

OSFM Report Number

This NFI report number format should follow this example: YYYYInitialsreportnumber (YYYYABC123)

Fire Agency Contact Name*

Contact Email*

Contact Phone Number*

Phone

Incident Information

Date of Fire*

Incident Number*

Occupancy

Select

Other Occupancy (please specify)

Detector Present

Select

Detector Activated

Select

Explain why the detector did not activate.

Victim Information

Victim Number*

Select

Injury Severity*

Select

Medical Examiner Case Number

Name*

First, Middle and Last Name

Gender

Select

Age

Date of Birth (if available)

MM/DD/YYYY

To submit additional fire victims related to this incident

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Please Note:

Incident Information

Victim Information

**To submit additional fire victims related to this incident**

To submit additional fire victims related to this incident