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Ohio Department of Public SafetyDivision of Emergency Medical Services
STATE OF OHIO NFPA 1403 BURN PLAN
BURN BUILDING LIVE FIRE EVOLUTIONSPRE-BURN PLAN*
FIRE CHARTER
FIRE CHARTER #
CHARTER ADDRESS
CHARTER PHONE #
PROGRAM DIRECTOR
PROGRAM DIRECTOR PHONE #
1403 BURN BUILDING
BUILDING ADDRESS
DATE OF LAST INSPECTION
AHJ
EMERGENCY PHONE #
*Required for compliance with NFPA 1403, Standard on Live Fire Training Evolutions.
BLANK PRE-BURN PLANS WILL NOT BE ACCEPTED
EMS 1287 3/21 [760-0983]
LIVE BURN DOCUMENT CHECKLIST
SHALL BE ON FILE NO CHANGE SINCE FILING
Burn building maintenance records
Burn building inspection records
Burn building engineering report to include floor plans
EPA Permit
Site plan that meets NFPA 1403
Site planning & equipment needs assessment checklist
Inclement weather SOG
Heat stress index chart - wind chill chart
Water Supply Needs
Live burn fuel package matrix
Instructor/support staff responsibilities
Written learning objectives for all evolutions w/diagrams
Emergency plan for Fire/Police/EMS
Emergency evacuation notification policy
DATE BURN PLAN FILED
PROGRAM DIRECTOR SIGNATURE
XPROGRAM DIRECTOR NAME (Printed)
Please submit this completed form with course request.
If changes have occurred, please include only those pages with course request.
EMS 1287 3/21 [760-0983]1
SITE PLAN THAT MEETS NFPA 1403 (Example)
# LOCATION # LOCATION
1 Burn Building 6 Staging
2 Restrooms 7 Roof Simulator
3 Drafting Pit 8 Storage
4 Rehab/Medical 9 Classroom
5 Storage 10 Incident Command
EMS 1287 3/21 [760-0983]2
1st Floor
EMS 1287 3/21 [760-0983]3
2nd Floor
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SITE PLAN THAT MEETS NFPA 1403 (Example)
1403 BURN BUILDING
BUILDING ADDRESS
DATE OF LIVE BURN
PRIMARY ENGINE
E162BACKUP ENGINE
E161ADDITIONAL APPARATUS
L23, M591
EMS 1287 3/21 [760-0983]5
COLD WEATHER WINDCHILL ASSESSMENTDATE
TIME
TEMPERATURE
WINDSPEED
CURRENT WINDCHILL
AHJ MINIMUM TEMPERATURE FOR OPS
AHJ MINIMUM WINDCHILL FOR OPS
YES NO Windchill is above AHJ Policy for Ops?PRINTED NAME
CERTIFICATION #
SIGNATURE DATE
EMS 1287 3/21 [760-0983]6
HOT WEATHER HEAT INDEX ASSESSMENTDATE
TIME
TEMPERATURE
WINDSPEED
CURRENT WINDCHILL
AHJ MAXIMUM TEMPERATURE FOR OPS
AHJ MAXIMUM WINDCHILL FOR OPS
YES NO Heat Index is above AHJ Policy for Ops?PRINTED NAME
CERTIFICATION #
SIGNATURE
XDATE
EMS 1287 3/21 [760-0983]7
INCLEMENT WEATHER GUIDELINE (Example)
The Instructor-in-charge shall have an awareness of weather conditions, wind velocity, and wind direction. They shall also do a final check for possible changes in weather conditions during burn time.The Instructor-in-charge and the Safety Officer shall always use discretion, common sense and the guidelines presented to make decisions for your safety and the safety of others. The Live Burn Instructor-in-charge, or the Safety Officer shall be responsible for implementing the appropriate actions
Inclement weather defined Rain, hail, sleet, excessive snow, sustained high winds, tornado watch or warning, high heat/stress index (greater than 85 degrees), low wind chill (below 20 degrees)Thunder and/or LighteningIf thunder is heard, or lightening is witnessed by any member, all outdoor training shall immediately cease and all members shall immediately seek indoor shelter. If equipment is laid out, leave it in place and seek shelter immediately. DO NOT use the burn building, forcible entry building, or training tower for shelterBefore outdoor training can resume, 20 minutes must pass without thunder heard and without lightening seenTornado WatchIf a tornado watch is issued, the Live Burn Instructor- in-charge or Safety Officer shall establish some means of communications to stay informed about the changing weather conditionsTornado WarningShould a tornado warning be issued, the designated shelter area shall be the main campus. DO NOT use the burn building, the training tower, or the training building. A PAR shall be conducted by the Instructor-in- charge, or Safety OfficerWindy ConditionsThe Instructor-in-charge or Safety Officer must always be aware of the prevailing wind and establish training scenarios that are not hampered by the wind. Certain training activities will need to be limited if windy conditions present a hazard to the student. Activities such as raising ground ladders, climbing aerial ladders, rope work, and the use of fire props may need to be cancelled or rescheduled. Sustained winds greater than 25 mph or gusty conditions with gusts greater than 25 mph shall be a benchmark for the Instructor-in-charge, or Safety Officer to consider modifying or rescheduling.Heat Stress IndexDetermine the Heat Index then, if applicable: add 10 degrees Fahrenheit for skills requiring the use of structural firefighter personal protective clothing.
Add 10 degrees Fahrenheit for skills conducted in direct sunlight.
If skills are conducted using structural firefighter personal protective clothing and in direct sunlight add 20 degrees Fahrenheit for both PPE and direct sunlight
INSTRUCTORS SHALL ENSURE THAT THE STUDENTS ARE ADEQUATELY HYDRATED AND THAT APPROPRIATE REST PERIODS ARE GIVEN TO ALLOW STUDENTS TO REHAB.
Wind Chill Factor
INSTRUCTORS SHALL ENSURE THAT THE STUDENTS HAVE ADEQUATE REST AND WARMING PERIODS.
ULTIMATELY, THE INSTRUCTOR-IN-CHARGE AND/OR THE SAFETY OFFICER CAN DELAY OR SUSPEND TRAINING.
EMS 1287 3/21 [760-0983]8
SEQUENTIAL LIVE FIRE – BURN MATRIXDATE
TIME
EVOLUTION 1COMPANY ROOM 1 ROOM 2 ROOM 3 ROOM 4
Ignition
Company A
Company B
Company C
Company D EVOLUTION 2
COMPANY ROOM 1 ROOM 2 ROOM 3 ROOM 4Ignition
Company A
Company B
Company C
Company D EVOLUTION 3
COMPANY ROOM 1 ROOM 2 ROOM 3 ROOM 4Ignition
Company A
Company B
Company C
Company D EVOLUTION 4
COMPANY ROOM 1 ROOM 2 ROOM 3 ROOM 4Ignition
Company A
Company B
Company C
Company D EVOLUTION 5
COMPANY ROOM 1 ROOM 2 ROOM 3 ROOM 4Ignition
Company A
Company B
Company C
Company D
EMS 1287 3/21 [760-0983]9
WATER SUPPLY NEEDS (Example)LEVEL OF 25% 50% 75% 100%
Estimated Fire Flow Exposure #1 Fire Flow Exposure #2 Fire Flow Exposure #3 Fire Flow Exposure #4 Fire Flow
Total Required Fire Flow
Required Reserve Flow (50%)
Total On Scene Engine Rated Pump Capacity (Shall Exceed Fire Flow)
NFA Fire Flow: Length x Width ÷ 3 x (# of Floors Involved) = 100% GPM
Required Exposure Fire Flow: 25% of base flow
EXAMPLE: 60’x 20’÷ 3 x 2 (floors) = 800 GPM (100%)
EXAMPLE: Exposure #1 Fire Flow: 200 GPM (25% of total base flow)
PRINTED NAME
CERTIFICATION #
SIGNATURE
XDATE
EMS 1287 3/21 [760-0983]10
INSTRUCTOR ROLES & RESPONSIBILITIES (Example)
Instructor-In-Charge (I.I.C.)1) Has overall responsibility of live fire training.2) Reviews and approves training plans.3) Monitor training activities to ensure safe practices and organizational SOP & SOG’s are followed.4) Conducts post burn evaluation of training staff and operations.5) Identifies and implements any opportunities to improve safety and burn operations.6) Communicates all concerns and safety violations to supervisor.
Lead Instructor (L.I.)
1) Plan and coordinate all required training activities.2) Monitor activities to ensure safe practices and organizational SOP & SOG’s are followed.3) Inspect building integrity prior to and after each Live Fire Training Evolution.4) Assign Staff & Radio:
a. Overall Safety Officerb. Lead Company Instructorsc. Company Safety Officersd. Ignition Officere. Fire Supportf. Pump/Accountability Officerg. Medical Surveillance/Rehab Officerh. Logisticsi. Radio Channel (when applicable)
5) Brief instructors & safeties on responsibilities:a. Accounting for assigned studentsb. Assessing student performancec. Monitoring Student PPEd. Monitoring operational safety.e. Achieving tactical and training objectives (Pre Burn Plan/outline).
6) Follows and monitors the Sequential Burn Plan.
Overall Safety Officer
1) Prevent unsafe acts.2) Eliminate unsafe conditions.3) Intervene and terminate unsafe acts.4) Supervise company safety officers.5) Responsible for the safety of all participants, visitors and spectators.6) Monitor activities to ensure safe practices and organizational SOP & SOG’s are followed.7) Monitor building conditions and training area.8) Monitor interior conditions by communicating with Company Safety Officers and Company Instructors after
company evolutions.9) Monitor Medical Surveillance and Rehab Officer Observations and findings.10) Inspect building integrity prior to and after each Live Fire Training offering.11) Ensure compliance of participant’s personal protective equipment with applicable standards.12) Ensure no more than nine (9) people are in structure during a Live Fire Training Evolution.13) Follows and monitors the Sequential Burn Plan.14) Ensure that all participants are accounted for, both before and after each live fire training evolution.15) Responsible for completing injury reports.
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INSTRUCTOR ROLES & RESPONSIBILITIES (Example)
Company Instructor1) Monitor and supervise assigned students (no more than five students) per Lead Instructor.2) Prevent unsafe acts.3) Intervene and terminate unsafe acts.4) Ensure compliance of participant’s personal protective equipment with applicable standards.5) Evaluate student performance against expected outcomes and recognized job performance requirements6) Account for assigned students, both before and after each Live Fire Training Evolution.7) Be alert to hazardous conditions and report them to the Overall Safety Officer.
Pump Officer
1) Establishes water supply for training.2) Responsible for emergency withdraw signal.3) Monitors pump pressure and engine.4) Personnel Accountability
Ignition & R.I.T. Officer
1) Establishes fire sets based on Live Fire Training Plan & SOP.2) Supervise Fire Support/R.I.T. staff.3) Coordinate fire attack with fueling operations4) Coordinates R.I.T. response during an emergency5) Follows the Sequential Burn Plan.6) Monitors Fire Support staff’s wellness.
Fire Support/R.I.T. Team
1) Constructs fire sets based on Live Fire Training Plan & SOP.2) Provides support role as back-up line.3) Monitors and maintains adequate training fires.4) Acts as R.I.T. Team in an emergency.5) Follows the Sequential Burn Plan.
EMS 1287 3/21 [760-0983]12
EVOLUTION – 1 (Example)LOCATION DATE
TIME
Evolution 1Instructions Entry on level 1 B side Garage advance Hose to the Living room for fire control.
Learning Objectives1. EXAMPLE: Fire behavior and growth2. EXAMPLE: Hoseline advancement3. EXAMPLE: Fog vs. Straight
EMS 1287 3/21 [760-0983]13
EVOLUTION – 2 (Example)LOCATION DATE
TIME
Evolution 2Instructions Entry on level 2 D side advance Hose around Hall to the storage room for fire control.
Learning Objectives1. EXAMPLE: Fire behavior and growth2. EXAMPLE: Hoseline advancement3. EXAMPLE: Fog vs. Straight
EMS 1287 3/21 [760-0983]14
EMERGENCY PLANSLOCATION ADDRESS
CITY
STATE
ZIP CODE
PERSONNEL / AGENCY EMERGENCY # OR CELL #AHJ
Law Enforcement
Fire Department
EMS
IC for Charter
Lead Instructor
Program Director
Total Cadets and Staff# OF CADETS
# OF STAFF
EMERGENCY PLAN - FIREACTIONS COMPLETED
Sound Evacuation Signal
Radio Announcement
Activate RIT
Deploy Back-Up Lines
Notify AHJ Dispatch and request appropriate Assignment
Conduct PAR
Request Additional Resources as needed
EMERGENCY PLAN - EMSACTIONS COMPLETED
Notify On-Site EMS
Notify AHJ Dispatch and request appropriate Response
Conduct PAR
Request Additional Resources as needed
EMERGENCY PLAN - POLICEACTIONS COMPLETED
Notify Location of Active Event
Lockdown or Evacuate
Notify AHJ Dispatch and request appropriate Response
EMS 1287 3/21 [760-0983]15
SHALL BE COMPLETED DAY OF LIVE BURN & KEPT IN COURSE FILE
Conducted Before Live Burn & Reviewed in Pre Burn BriefingACTIONS COMPLETED
Cadet prerequisites met
Instructor List w/Certifications
Review heat stress/wind chill chart for compliance
Incident command organizational chart
Communications plan
Medical plan
Instructor/support staff/cadet assignments
Instructor to cadet ratio (SHALL MAINTAIN 5:1 MIN.)
SCBA & gear inspection
Go/No Go Checklist
CONDUCTED DURING LIVE BURNACTIONS COMPLETED
Rest and rehab for each evolution w/vital sign monitoring
Evolution checklist
Evolution log
REVIEWED AND PREPARED BYPRINTED NAME
CERTIFICATION #
SIGNATURE
XDATE
EMS 1287 3/21 [760-0983]16
CADET TRAINING VERIFICATIONPrior to being permitted to participate in live fire training evolutions, the Cadet shall have received training to meet the minimum job performance requirements for Fire Fighter I of the NFPA 1001, Standard for Fire Fighter Professional Qualifications, related to the following subjects:
1. Safety 2. Fire behavior 3. Portable extinguishers
4. PPE 5. Ladders 6. Fire Hose, appliances & streams
7. Overhaul 8. Water supply 9. Ventilation
10. Forcible entry 11. Forcible entry Course #
I verify that the Cadets in the above listed course are physically fit and have met the education requirements stated above. I also do hereby authorize the individuals to participate in this training session.PRINTED NAME
CERTIFICATION #
SIGNATURE
XDATE
FIRE INSTRUCTORS / LIVE BURN INSTRUCTORS / ASSISTANT FIRE INSTRUCTORSInclude all staff that will be assisting in the instruction and testing of the Cadets. Ensure that the ratio of Cadets to instructors does not exceed five to one during all practical skills instruction or evaluation.
Instructors/Support Staff
Name Assignment Cert. Level
Cert.Number
VerifiedDate
Initials
TOTAL NUMBER OF INSTRUCTORS
TOTAL NUMBER OF CADETS
CADET TO INSTRUCTOR RATIO :
I affirm, with my signature, that each instructor holds a current and valid fire instructor certificate, instructors are employed or contracted by the chartered program and instructors are teaching courses at or below the level of an instructor's fire training certificate.PRINTED NAME
CERTIFICATION #
SIGNATURE
XDATE
EMS 1287 3/21 [760-0983]17
INCIDENT COMMAND ORGANIZATIONAL CHARTLOCATION DATE
TIME
REVIEWED AND PREPARED BYPRINTED NAME
CERTIFICATION #
SIGNATURE
XDATE
EMS 1287 3/21 [760-0983]18
COMMUNICATION PLAN
PERSONNEL / AGENCY RADIO CHANNEL ASSIGNED COMMENTS
Instructor-in-Charge, IC, Safety
Fire Control Team to Instructor-in-Charge
Burn Instructors to Instructor-in-Charge
Ignition Team
RIT
Cadets
Support Staff
Security
Fire Department
EMS
Law Enforcement
Air Medical
Power Company
Water Company
Natural Gas Company
MEDICAL PLAN
On-Scene EMS (REQUIRED FOR ALL LIVE BURNS)Agency
Level of Care
Transport Capabilities
Location
Emergency #
Emergency Radio Channel
CLOSEST HOSPITALHospital
Location
Estimated Transport Time
Emergency #
EMS 1287 3/21 [760-0983]19
CADET / COMPANY ASSIGNMENT LOGLEAD INSTRUCTOR
TIME
PRIMARY CHANNEL
SUPPORT CHANNEL
A COMPANYROLE NAME CERT. or ID # NOTES
Instructor
Cadet
Cadet
Cadet SAFETY OFFICERS
Cadet 1.
Cadet 2.
B COMPANYROLE NAME CERT. or ID # NOTES
Instructor
Cadet
Cadet
Cadet SAFETY OFFICERS
Cadet 1.
Cadet 2.
C COMPANYROLE NAME CERT. or ID # NOTES
Instructor
Cadet
Cadet
Cadet SAFETY OFFICERS
Cadet 1.
Cadet 2.
D COMPANYROLE NAME CERT. or ID # NOTES
Instructor
Cadet
Cadet
Cadet SAFETY OFFICERS
Cadet 1.
Cadet 2.
EMS 1287 3/21 [760-0983]20
INSTRUCTOR / SUPPORT STAFF ASSIGNMENT LOGLEAD INSTRUCTOR
TIME
PRIMARY CHANNEL
SUPPORT CHANNEL
EMERGENCY RADIO
EVACUATION SIGNAL
Airhorn Blast – 60 Seconds
ASSIGMENTSROLE NAME CERT. LEVEL NOTES
Instructor-in-Charge (IC)
Overall Safety (SO)
Ignition Officer
Ignition Support 1
Ignition Support 2
Ignition Support 3
Rehab Officer
Pump Operator-Primary
Pump Operator - Backup
Medical Officer
Medical Support
Logistic:
Other RAPID INTERVENTION TEAM
In-Charge (IC)
Instructor
Instructor A COMPANY
Instructor
Safety Officer B COMPANY
Instructor
Safety Officer C COMPANY
Instructor
Safety Officer D COMPANY
Instructor
Safety Officer
EMS 1287 3/21 [760-0983]21
PPE / SCBA INSPECTION – INSTRUCTORSINSTRUCTORS CONDUCTING INSPECTIONS CERTIFICATION #
1.
2.
3.
# INSTRUCTOR NAMES
ID / U
nit #
Coat
Pants
Boots
Gloves
Hood
Helm
et
SCB
A
Facepiece
Air B
ottle
PASS
Radio
Flashlight
Eye Pro
Initials
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
I verify that the above gear has passed inspection and is approved for live fire training in accordance with NFPA 1403.PRINTED NAME
CERTIFICATION #
SIGNATURE
XDATE
EMS 1287 3/21 [760-0983]22
PPE / SCBA INSPECTION – CADETSINSTRUCTORS CONDUCTING INSPECTIONS CERTIFICATION #
1.
2.
3.
# CADET NAMES
ID / U
nit #
Coat
Pants
Boots
Gloves
Hood
Helm
et
SCB
A
Facepiece
Air B
ottle
PASS
Radio
Flashlight
Eye Pro
Initials
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
I verify that the above gear has passed inspection and is approved for live fire training in accordance with NFPA 1403.PRINTED NAME
CERTIFICATION #
SIGNATURE
XDATE
EMS 1287 3/21 [760-0983]23
GO / NO-GO CHECKLIST
Complete Before Each EvolutionNAME
DATE
WEATHER / TEMP
/ TIME
GO / NO-GO Checklist COMPLETED
Burn-Plan Review Completed
Safety Officer
Medical Officer
Pump Operator
Accountability Officer
Ignition Officer
Logistics
A Company
B Company
C Company
D Company
Attack Lines / Back-up Lines Flowed
Check Nozzle Pattern
Radio Check
EMS In-Service
GO / NO-GO Checklist COMPLETEDBurn-Plan Review Completed
Safety Officer
Medical Officer
Pump Operator
Accountability Officer
Ignition Officer
Logistics
A Company
B Company
C Company
D Company
Attack Lines / Back-up Lines Flowed
Check Nozzle Pattern
Radio Check
EMS In-Service
EMS 1287 3/21 [760-0983]24
REHAB LOG - INSTRUCTORS (Example)Rehab Location
Rehab Officer
Access to bathroom or portable toilet. Fresh drinking water and cups.Meal for each person at the drill. Sitting area with adequate chairs.Towels/baby wipes for decon/hand sanitizer. Temperature appropriate: cooling fans/heaters.Waste container.
INSTRUCTOR ID #Base Line Evolution #1
Time Temp. H.R. R.R. B.P. Pulse Ox. Time Temp. H.R. R.R. B.P. Pulse
Ox.
*Please Refer to NFPA 1584 for Rehab Guidelines*
EMS 1287 3/21 [760-0983]25
REHAB LOG - CADETS (Example)Rehab Location
Rehab Officer
Access to bathroom or portable toilet. Fresh drinking water and cups.Meal for each person at the drill. Sitting area with adequate chairs.Towels/baby wipes for decon/hand sanitizer. Temperature appropriate: cooling fans/heaters.Waste container.
Cadet ID #Base Line Evolution #1
Time Temp. H.R. R.R. B.P. Pulse Ox. Time Temp. H.R. R.R. B.P. Pulse
Ox.
*Please Refer to NFPA 1584 for Rehab Guidelines*
EMS 1287 3/21 [760-0983]26
EVOLUTION CHECKLIST
Complete During Each EvolutionSTART TIME
END TIME
DATE
Evolution Checklist #1 #2 #3 #4
Full PPE w/SCBA (No Exposed Skin)
Maintain Accountability
Check Nozzle before entry
All team members have a tool
TIC
Victim in place (No live victims during live fire training)
Search Pattern Completed
Victim Located
Victim Removed
Building properly ventilated
Company properly communicated with Command
Conduct PAR per SOG and at completion of evolution
Temperatures monitored
EMS 1287 3/21 [760-0983]27
EVOLUTION LOGDATE
TIME
EVOLUTION 1
Company Time In Time Out
Temperature MonitoringHall Stairs Door Floor Ceiling Door Floor Ceiling
Alpha
Bravo
Charlie
Delta
EVOLUTION 2
Company Time In Time Out
Temperature MonitoringHall Stairs Door Floor Ceiling Door Floor Ceiling
Alpha
Bravo
Charlie
Delta
EVOLUTION 3
Company Time In Time Out
Temperature MonitoringHall Stairs Door Floor Ceiling Door Floor Ceiling
Alpha
Bravo
Charlie
Delta
EVOLUTION 4
Company Time In Time Out
Temperature MonitoringHall Stairs Door Floor Ceiling Door Floor Ceiling
Alpha
Bravo
Charlie
Delta
EVOLUTION 5
Company Time In Time Out
Temperature MonitoringHall Stairs Door Floor Ceiling Door Floor Ceiling
Alpha
Bravo
Charlie
Delta
EMS 1287 3/21 [760-0983]28
SHALL BE COMPLETED AFTER LIVE BURN & KEPT IN COURSE FILE COMPLETED
AAR (After Action Review)
Cadet/Instructor Discharge Instructions
Instructor List w/Certification #’s (Updated if Needed)
YES NO SHALL BE COMPLETED AS NEEDED & KEPT IN COURSE FILE Date Initials
First Report of Injury (DEMS Notified)
First Report of Un-Safe Act (DEMS Notified)
COMMENTS
REVIEWED AND PREPARED BYPRINTED NAME
CERTIFICATION #
SIGNATURE
XDATE
EMS 1287 3/21 [760-0983]29
CRITIQUE / AAR (After Action Review)DATE
TIME
INSTRUCTORS/STAFF RECOMMENDATIONS
Priority Item LeadInitials Implemented
CADET RECOMMENDATIONS
Priority Item LeadInitials Implemented
REVIEWED AND PREPARED BYPRINTED NAME
CERTIFICATION #
SIGNATURE
XDATE
EMS 1287 3/21 [760-0983]30
CADET / INSTRUCTOR DISCHARGE INSTRUCTIONS
Review ChecklistWash hands and face before eating and drinking Drink a minimum of 16 oz. of waterShower ASAP to wash off carcinogens Change your clothesLaunder your clothes separately Eat a nutritious mealWash PPE including helmet, hoods and gloves Consume 32 oz. or more of water throughout eveningAll injuries shall be reported to Program Director within 24 hrs.
16 FIREFIGHTER LIFE SAFETY INITIATIVES
THE NATIONAL FALLEN FIREFIGHTERS FOUNDATION’S EVERYONE GOES HOME® PROGRAM1. Define and advocate the need for a cultural change within the fire service relating to safety;
incorporating leadership, management, supervision, accountability and personal responsibility.
2. Enhance personal & organizational accountability for health & safety in the fire service3. Focus greater attention on the integration of risk management with incident management at all
levels, including strategic, tactical, and planning responsibilities.4. All firefighters must be empowered to stop unsafe practices.5. Develop and implement national standards for training, qualifications, and certification (including
regular recertification) that are equally applicable to all firefighters based on the duties they are expected to perform.
6. Develop and implement national medical and physical fitness standards that are equally applicable to all firefighters, based on the duties they are expected to perform.
7. Create a national research agenda and data collection system that relates to the initiatives.8. Utilize available technology wherever it can produce higher levels of health and safety.9. Thoroughly investigate all firefighter fatalities, injuries, and near misses.10. Grant programs should support the implementation of safe practices and/or mandate safe
practices as an eligibility requirement.11. National standards for emergency response policies and procedures should be developed and
championed.12. National protocols for response to violent incidents should be developed and championed.13. Firefighters and their families must have access to counseling and psychological support.14. Public education must receive more resources and be championed as a critical fire and life
safety program.15. Advocacy must be strengthened for the enforcement of codes and the installation of home fire
sprinklers.16. Safety must be a primary consideration in the design of apparatus and equipment.
EMS 1287 3/21 [760-0983]31
FIRST REPORT OF INJURYName: Phone #:
Age: Gender:
Injury Date: Injury Time:
Injury Location: City/State/Zip:
Nature of Injury: EMS Agency:
Transport Facility: Injured Status:
Course: Course #:
Witness: Witness Cell:
Injury Details1. What task was the injured person performing?
2. How was the person injured?
3. Factors contributing to the injury?
4. Were there any unsafe acts leading to the injury, if so please describe?
5. Did any equipment or apparatus fail? Please describe any equipment or apparatus failures.
6. What steps should be taken to prevent similar injuries?
7. Was injury immediately reported? If no, please explain.
Injury Report Narrative
PRINTED NAME
CERTIFICATION #
SIGNATURE
XDATE
EMS 1287 3/21 [760-0983]32
FIRST REPORT OF UNSAFE ACTName Phone #
Age Cadet or Staff
Event Date Event Time
Event Location City/State/Zip
Nature of Event Injuries
Course Course #
Incident Details1. What task was the cadet/instructor person performing?
2. What was the unsafe act?
3. How was the cadet/instructor being supervised?
4. Was any equipment and/or apparatus being used?
5. What steps should be taken to prevent similar unsafe acts?
6. Was the unsafe act immediately reported? If no, please explain.
7. Would this incident have resulted in an injury? If yes, please explain.
Incident Narrative
PRINTED NAME
CERTIFICATION #
SIGNATURE
XDATE
EMS 1287 3/21 [760-0983]33
Ohio Department of Public SafetyDivision of Emergency Medical Services
APPENDIX AACQUIRED STRUCTURELIVE FIRE EVOLUTIONS
PRE-BURN PLAN*
*Required for compliance with NFPA 1403, Standard on Live Fire Training Evolutions
BLANK PRE-BURN PLANS WILL NOT BE ACCEPTED
EMS 1287 3/21 [760-0983]34
ACQUIRED STRUCTURE CHECKLISTBuilding Address:
Building Description:
Initial Fire Assignment:
Unique Hazards Present:
Lead Instructor: Instructor Cell:
AHJ: AHJ Chief:
AHJ Emergency #: Non-Emergency #:
Property Owner: Owner Cell:
Property Manager: Management Cell:
Occupancy Type: Construction Type:
Roof Construction: Floor Construction:
Number of Floors: Total Square Foot:
Year Built: Basement:
Hydrant Location #1: Available Flow:
Hydrant Location #2: Available Flow:
YES NO ACTION DATE INITIALS
Proof of Clear Title
Proof of insurance cancellation
Fire Department Liability Insurance Coverage
Local/Regional Law Enforcement Notice
Notice to Adjacent Property Owners
Utility Notification: Gas, Electric, Water
EPA Permit
Asbestos Inspection
Asbestos Mitigation
Acquired Structure Preparation Checklist
Owners release to damage and/or burn structure
Acknowledgment of Building use & Post burn condition
Completion of Burn transfer to AHJ
Transfer of authority back to property owner
Site plan that meets NFPA 1403
Site planning & equipment needs assessment checklist
COMMENTS
DATE BURN PLAN FILED
PROGRAM DIRECTOR SIGNATURE
X*Please submit pages 35-45 with course request.
EMS 1287 3/21 [760-0983]35
ACQUIRED STRUCTURE PLAN - PROOF OF CLEAR TITLEBuilding Address:
EMS 1287 3/21 [760-0983]36
ACQUIRED STRUCTURE PLAN - PROOF OF INSURANCE CANCELLATIONBuilding Address:
EMS 1287 3/21 [760-0983]37
ACQUIRED STRUCTURE PLAN - FIRE DEPARTMENT LIABILITY INSURANCE COVERAGEBuilding Address:
Most political subdivisions and their fire departments have liability insurance which covers any acts or omissions that may take place during a structural burn.
Fire department members are covered under the Workers Compensation plan obtained by the political subdivision to which the fire department belongs.
If this training is not being conducted through a state education institution, such as the Minnesota State Colleges and Universities institution, remember to obtain liability insurance to cover the unexpected problems that may come up. This should include exposure and medical, plus anything else you might be concerned about.
CITY/TOWNSHIP LIABILITY INSURANCE OBTAINED: Yes No
DOCUMENTATION ENCLOSED: Yes No
Fire Chief:
Fire Department:
Date:
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ACQUIRED STRUCTURE PLAN – ASBESTOS INSPECTION / MITIGATIONBuilding Address:
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ACQUIRED STRUCTURE PLAN – EPA PERMITBuilding Address:
EPA Permit #: Permit Dates:
EPA Inspector: Inspector Phone:
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ACQUIRED STRUCTURE PLAN – OWNERS RELEASE TO DAMAGE OR BURN STRUCTUREBuilding Address:
Legal Description:
City: County:
Building Official: BO Phone:
Having agreed with the building official, City or
County of , that a structure owned by
and located at the following address:
County of , Township of ,
In the City of with Nearest Cross Road of .
Is under condemnation or unfit for human habitation and is beyond rehabilitation. I further agree that the structure
should be used by the fire service for training as they see fit. In order that demolition may be accomplished, I give
my consent to the City/Township of to use or demolish the
said structure by burning or other means.
OWNER SIGNATURE
XDATE
OWNER SIGNATURE
XDATE
BUILDING OFFICIAL SIGNATURE
XDATE
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TRAINING SITE LOCATION - EXAMPLEFull Building Address: 1007 Mountain Drive, Gotham City, Ohio
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ACQUIRED STRUCTURE 1ST FLOOR PLANS - EXAMPLE
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ACQUIRED STRUCTURE 2nd FLOOR PLANS - EXAMPLE
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ACQUIRED STRUCTURE SITE PLANS - EXAMPLEBuilding Address:
Dates of Live Burn:
Primary Engine: E162 Backup Engine: E161
Additional Apparatus: L23, M591
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