OSFM Fire & Rescue Training Injury Investigation Reports

Training Injury Report

The purpose of this form is to Report Injuries during training to the North Carolina Office of the State Fire Marshal.

Indicates required field

Date of Injury

First Name of Person Reporting Injury

Last Name of Person Reporting Injury

Training Description

Location

Delivery Agency

Instructor in Charge

Total Number of Training Participants

Number of Instructors Deemed Qualified

Injured Age

Years of Service

Pre-injury Activities at Training Exercise

Type of training being conducted:

The instructor qualifications of the instructor in charge

Other

Was this class taught through a NCF&RC delivery agency?

Yes

Was there damage to injured personnel's protective equipment?

Yes

Was the injured firefighter wearing a SCBA at the time of the incident?

Yes

Was a Safety Officer assigned at the time of injury?

Yes

Comments

Detailed description of injury

Type of Agency

Classify the injury from the following categories

Sprain

Wound

Respiratory

Burn

Heart

Thermal

Other

Other injury Type

Was this North Carolina Fire and Rescue Commission (NCF&RC) certification class?

Yes

Is instructor certified as a General Level II instructor?

Yes