Fire Screening Summary Form

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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 *

Is there a smoker in the home? *

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
Referrals
In The News
Files
Instructors Only
- NoFIRES data
Fire Screening Summary Form