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Fire Incident Report: Complete and and Fax One Copy To The Appropriate Agency Field Office (See Fax Numbers At: HTTP

This fire incident report provides details of a fire that occurred at a licensed facility. It requests information such as the facility type and location, date and time of the fire, its location within the building, who reported it and how it was detected. It also asks if an evacuation was necessary, how many were evacuated, and if smoke compartmentation was used. Further, it inquires about any deaths or injuries, the type of firefighting equipment used, the probable cause of the fire, damage details, estimated dollar loss, prevention steps taken, and fire department participation. The report is to be completed and sent within 15 days of the incident.

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329 views

Fire Incident Report: Complete and and Fax One Copy To The Appropriate Agency Field Office (See Fax Numbers At: HTTP

This fire incident report provides details of a fire that occurred at a licensed facility. It requests information such as the facility type and location, date and time of the fire, its location within the building, who reported it and how it was detected. It also asks if an evacuation was necessary, how many were evacuated, and if smoke compartmentation was used. Further, it inquires about any deaths or injuries, the type of firefighting equipment used, the probable cause of the fire, damage details, estimated dollar loss, prevention steps taken, and fire department participation. The report is to be completed and sent within 15 days of the incident.

Uploaded by

benon
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as PDF, TXT or read online on Scribd
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FIRE INCIDENT REPORT

Complete and Email one copy to the Office of Plans and Construction at: [email protected]
and Fax one copy to the appropriate Agency Field Office (see fax numbers at: http://
ahca.myflorida.com/MCHQ/Field_Ops/Field_Office_Info.shtml) within 15 days of the incident)

Facility Type: SELECT

Licensed Facility Name:


Licensed Facility Address/City:

Fire or Explosion: Date Time AM PM

Location of fire within facility (Building):

Name and title of person reporting fire:

Alarm/Signal device used: Pull Detector

Other / Phone

Was evacuation of facility necessary: Yes No


If yes, how many were evacuated:
Was smoke compartmentation utilized for evacuation? If so, describe.

Were there any deaths? Yes No

Were there any injuries? Yes No If yes, how many and describe injuries

OFFICE OF PLANS AND CONSTRUCTION TEL: 850/412-4477 FAX: 850/922-6483


AHCA Form 3500-0031, July 2014 Sections 59A-4.130(2), 59A-26.016(5), 59A-3.077(2), F.A.C.
Page 1 of 2 Form available at: http://ahca.myflorida.com/plansandconstruction
Type of firefighting equipment used to extinguish fire:

Water Hose Dry Chemical Fire Extinguisher

CO2 Halon None Other

Known or probable cause of fire:

____________________________________________________________________________

Extent of flame, smoke, water or other damage:

____________________________________________________________________________

____________________________________________________________________________

Estimated amount of dollars loss: $

What steps have been taken by the facility to prevent reoccurrence?

____________________________________________________________________________

____________________________________________________________________________

Describe the local fire department participation.

____________________________________________________________________________

____________________________________________________________________________

Name & Title of Person Making this Report

Signature of Person Making this Report Date of Report

OFFICE OF PLANS AND CONSTRUCTION TEL: 850/412-4477 FAX: 850/922-6483


AHCA Form 3500-0031, July 2014 Sections 59A-4.130(2), 59A-26.016(5), 59A-3.077(2), F.A.C.
Page 2 of 2 Form available at: http://ahca.myflorida.com/plansandconstruction

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