Free Fire Report-F-62500 - Wisconsin

DEPARTMENT OF HEALTH SERVICES Division of Quality Assurance F-62500 (Rev. 04/09)

STATE OF WISCONSIN Chapter 50.035(4), Wis. Stats.

FIRE REPORT
All incidents of fire in an adult family home (AFH), a community based residential facility (CBRF), a facility serving people with developmental disabilities (FDD), a hospital, a nursing home, or a residential care apartment complex (RCAC) must be reported to the department within 72 hours per DHS 132.82(6)(e), DHS 134.82(4)(e), DHS 83.12(4)(e), DHS 124.36(11), DHS 88.05(4)(e), Wis. Admin. Code, and Chapter 50.035(4), Wis. Stats. Information about the fire may be reported by completing and submitting this form; however, it is not mandatory that you use this form. Include sketches, photographs, reports or statements, if available. Questions about completion of this form may be directed to the Fire Authority at 608-261-5993. Mail the form and attachments to: FIRE AUTHORITY DQA / Bureau of Technology, Licensing and Education P.O. Box 2969 Madison, WI 53701-2969 or FAX to 608-267-7119
Name - Facility License / Provider Number



Address

Date of Fire

City

Time of Fire

PM AM

Type of Provider

AFH

CBRF

FDD

Hospital

Nursing Home

RCAC

Type of Fire (Provide narrative description. Use the back of this form to provide additional information.)

Location of Fire in the Facility

Was anyone injured?

Total Number Injured

Number of Residents

Number of Staff

Number of Others

Yes Room Yes

No
Residents were, or are, relocated to other facilities or locations.

Residents were evacuated from

Floor No

Wing

Building Manual Pull Station Yes No

Yes Heat Detector

No Smoke Detector Yes Sprinkler System No

The fire alarm system was activated. Number of Sprinkler Heads Activated The fire was extinguished by

Method of Activation A follow-up call was made to the fire department. Method of Fire Extinguishment The fire department responded.

Staff

Fire Dept.

Others Yes Yes No No Estimated Cost of Repairs $

Is the fire alarm system restored to normal working condition? Is the sprinkler system restored to normal operation condition?

Name and Title - Person Completing This Report

Telephone Number

SIGNATURE - Person Completing This Report

Date Report Completed