Online Form

Fireworks Incident Reporting Form


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