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New Hampshire Department of Safety New Hampshire Department of Safety
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Fireworks Incident Reporting Form



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SECTION A – REPORTING AGENCY INFORMATION

 
 
1.   Agency Name    (Type Answer)
 
(40 character limit; 40 remaining.)
 
2.   FDID#    (Type Answer)
 
(30 character limit; 30 remaining.)
 
3.   Address    (Type Answer)
 
(50 character limit; 50 remaining.)
 
4.   Telephone Number (Example: 999-111-0000)
  Ext:
 
5.   Contact Person    (Type Answer)
 
(100 character limit; 100 remaining.)
 
6.   Firework Incidents    (Select one)
  Please retrieve our fireworks incidents from the NFRIS data base.   
This agency has no firework related incidents to report.   
 

SECTION B – INCIDENT INFORMATION

 
 
7.   Incident    (Select one)
  Fire    Injury    Other     
 
8.   Location of Incident:    (Select one)
  Residential    Commerical    Public property    Open fields/woodlands    Other     
 
9.   Date (Example: MM/DD/YYYY)
 
 
10.   Time    (Type Answer)
 
(20 character limit; 20 remaining.)
 
11.   Incident #    (Type Answer)
 
(100 character limit; 100 remaining.)
 
12.   Gender    (Type Answer)
 
(10 character limit; 10 remaining.)
 
13.   Age    (Type Answer)
 
(10 character limit; 10 remaining.)
 
14.   Adult Present    (Select one)
  Yes    No    N/A   
 
15.   Do you have a local ordinance for fireworks    (Check all that apply)
  Prohibition of all Permissible Fireworks Ordinance #     
Permit required for display of Permissible Fireworks Ordinance #     
Display of Permissible Fireworks prohibited Ordinance #     
Follow NH RSA 160 C only   
 

SECTION C – INJURY INCIDENT DETAILS

 
 
16.   Injury location    (Check all that apply)
  Head/Face    Hand    Arm    Leg/Foot    Torso   
 
17.   Type of injury    (Check all that apply)
  Burn Injury - 1st Degree    Burn Injury - 2nd Degree    Burn Injury - 3rd Degree    Traumatic Injury    Amputation   
 
18.   Patient transported to    (Type Answer)
 
(100 character limit; 100 remaining.)
 
19.   Cause of Injury    (Check all that apply)
  Tampering with fireworks    Leaning over fireworks    Duds Relight or handling    Unsafe surface    Throwing fireworks    Holding in hand    Other     
 

SECTION D – FIRE INCIDENT DETAILS

 
 
20.   Type of fire    (Select one)
  Wildland    Structure Fire (List occupancy type)     
 
21.   Fire Cause    (Check all that apply)
  Accidental - Dollar loss      Incendiary - Dollar loss     
 
22.   If Incendiary, was an investigation conducted?    (Select one)
  Yes, by whom      No   
 

SECTION E – DEVICE INFORMATION

 
 
23.   Devices    (Check all that apply)
  NH Prohibited Item (Firecrackers, Bottle Rockets and Smoke devices) Where were the items purchased?     
Class B Display Fireworks   
Federal banned explosive device (M-80, Cherry Bombs, Block Busters, Quarter Stick, etc.)   
Unknown   
 
24.   NH Permissible Item    (Select one)
  Reloadable Mortar   
Aerial Device   
Ground Device   
Sparkler   
Other     
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