Preparer's Name:     Date Reported to Manager: (MM/DD/YY) 
Type:                                           Date of Incident:(MM/DD/YY)     Time:    
Building Evacuated:
Shift:
Day of Week:
Site Location:
Department:
Exact Location of Fire:
Cause of Fire:
Fire Extinguisher Used:       Who Extinguished fire:
Extinguisher or Sprinkler Head Location/ID:
Impact Due to Fire: Employee Injuries       If yes, Name:
  Downtime Due to Fire: Explain:
Building or Equipment Damage:
Description of Incident:
Containment/Interim Corrective Action Identified/Completed: