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Youth Firesetting
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NoFIRES data
Fire Screening Summary Form
Fire Screening Summary Form
*
Indicates required field
Screening Date (mm/dd/yy)
*
Youth Name
*
First
Last
Address
*
Line 1
Line 2
City
State
Zip Code
Country
Location of Fire (check all that apply)
*
Commercial/Retail Building
Dumpster
Home
Neighborhood Building
Public/Neighborhood Land
School Building
School Property
Street/Alley/Sidewalk
Vehicle - Family
Vehicle - Other
Cologne/Body Spray
Other
Unknown
Estimated amount of damage
*
Cost of Response
Less than $100
$100-$1,000
$1,000-$5,000
$5,000-$10,000
$10,000-$25,000
$25,000-$50,000
$50,000-$100,000
$100,000-$250,000
$250,000-$500,000
More than $500,000
Is there a smoker in the home?
*
Yes
No
Unknown
Fire Description (check all that apply)
*
Misuse of fire
Explosive
False alarm
Accelerant
Bomb threat
Unknown
Other
Fire Behavior (check all that apply)
*
Delinquent - solo
Delinquent - with siblings
Delinquent - with peers
Curiosity
Crisis
Ignition Sources (check all that apply)
*
Matches/lighter
Candle
Chemical reaction
Cigarette/other smoke
Cooking/heating appliance
Fireworks/road flare
Not applicable
Unknown
Other
Previous Incidents
*
0
1-2
2-5
6-10
11-25
26 or more
Unknown
Fire Safety Inspection (check all that apply)
*
Working smoke detectors
Detector tested regularly?
CO detectors
Fire extinguishers
Sprinkler system
Fire escape plan
Ignition materials accessible
Visible fire hazards
Blocked exits
Child-proof devices
Smokers in the home
Other
Did this home pass the fire safety inspection?
*
Yes
No
If no, please describe your concerns (be specific)
*
Firefighter Recommendations
NoFires Class
*
Youth
Child
Individual education
Not Recommeded for NoFIRES
If not recommended, please explain
*
Additional comments
*
Reported by:
Name
*
First
Last
Date (mm/dd/yy)
*
Email
*
Submit
Home
About
Meet the Team
Contact
Youth Firesetting
Prevention
Conferences
2022 Conference
2021 Conference
2020 Conference
2019 Conference
2018 Conference
2018 Conference Photos and Video
2017 Conference Photos and Video
2017 Conference Agenda
2016 Conference - Burn Demo Video
2016 Conference Photos
W9 Form
Referrals
In The News
Files
Instructors Only
NoFIRES data
Fire Screening Summary Form